Form DE1378A "Application for Unemployment Insurance, State Disability Insurance, and Paid Family Leave Elective Coverage Under Section 708(A) of the California Unemployment Insurance Code (Cuic)" - California

What Is Form DE1378A?

This is a legal form that was released by the California Employment Development Department - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2016;
  • The latest edition provided by the California Employment Development Department;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DE1378A by clicking the link below or browse more documents and templates provided by the California Employment Development Department.

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Download Form DE1378A "Application for Unemployment Insurance, State Disability Insurance, and Paid Family Leave Elective Coverage Under Section 708(A) of the California Unemployment Insurance Code (Cuic)" - California

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APPLICATION FOR UNEMPLOYMENT INSURANCE, STATE DISABILITY INSURANCE, AND PAID FAMILY LEAVE
ELECTIVE COVERAGE UNDER SECTION 708(a) OF THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE (CUIC)
Complete this application only if you meet the requirements as set forth
FOR DEPARTMENT USE ONLY
0B
in the attached Information Concerning Elective Coverage.
DIEC
-
-
APPROVED:
DENIED:
ACCOUNT #
NOTE: For assistance in completing this application, contact the nearest
EFFECTIVE DATE
SUBJECT
Employment Tax Office or call 888-745-3886. Upon completion of the
-
QUARTER
application, return to:
Attention: Analysis Resolution and Correspondence Organization
SEND FORMS
Employment Development Department
DE 2515, DE 3816DI, DE 1378DI
DE 3DI QTR(S)
PO Box 2068
Rancho Cordova, CA 95741-2068
DATE FORMS SENT:
APPROVED BY:
APPROVAL DATE:
PLEASE TYPE OR PRINT ALL INFORMATION CLEARLY.
ON-LINED BY:
ON-LINED DATE:
1.
SOCIAL SECURITY NUMBER*
2.
EMPLOYER ACCOUNT NUMBER
3.
GENDER
4. YEAR OF BIRTH
-
-
-
-
MALE
FEMALE
5. FIRST NAME
MIDDLE INITIAL
LAST NAME
6.
HAVE YOU APPLIED FOR ELECTIVE
COVERAGE BEFORE?
YES
NO
IF YES, ______
______
MO.
YR.
7. MAILING ADDRESS: NUMBER AND STREET OR PO BOX
CITY
ZIP CODE
8. BUSINESS NAME (IF ANY)
BUSINESS PHONE
(
)
9. BUSINESS ADDRESS: NUMBER AND STREET OR PO BOX
CITY
ZIP CODE
10.
EMAIL ADDRESS
11. WEBSITE
12.
DO YOU HAVE ANY EMPLOYEES?
IF YES, AND YOU ARE NOT REGISTERED WITH THE EMPLOYMENT DEVELOPMENT DEPARTMENT (EDD)
AS AN EMPLOYER, PLEASE EXPLAIN:
YES
NO
IF NO, SEE INSTRUCTIONS
13.
TYPE OF ORGANIZATION:
CORPORATION – DO NOT SUBMIT, CORPORATE OFFICERS ARE EMPLOYEES AND COVERED
GENERAL PARTNERSHIP (INCLUDES HUSBAND AND WIFE CO-OWNERS WHO ARE BOTH ACTIVE IN THE OPERATION AND
MANAGEMENT OF THE BUSINESS)
INDIVIDUAL
LIMITED PARTNERSHIP – ONLY GENERAL PARTNERS MAY APPLY
LIMITED LIABILITY PARTNERSHIP – ONLY GENERAL PARTNERS MAY APPLY
LIMITED LIABILITY COMPANY – PARTNERSHIP
LIMITED LIABILITY COMPANY – SOLE PROPRIETORSHIP MANAGING MEMBER
14. NAME(S) AND TITLE OF ALL PARTNERS AND MEMBERS (CONTINUE ON ANOTHER PAGE IF NECESSARY)
GENERAL PARTNERS/MEMBERS
SOCIAL SECURITY NUMBER*
LIMITED PARTNERS/MEMBERS
SOCIAL SECURITY NUMBER*
15.
NATURE OF BUSINESS:
CONTRACTING
MANUFACTURING
REPAIRING
RETAIL TRADE
SERVICE
WHOLESALE TRADE
OTHER (DESCRIBE):
16.
YOUR OCCUPATION/TITLE
17. DESCRIBE THE TYPE OF SERVICE, TYPE OF CONTRACTING, OR PRODUCT SOLD.
18.
IS A LICENSE OR PERMIT REQUIRED IN YOUR TRADE, BUSINESS OR OCCUPATION?
DO YOU POSSESS SUCH A
PROVIDE LICENSE/PERMIT NUMBER
YES
NO
IF YES, INDICATE TYPE OF LICENSE OR PERMIT REQUIRED:
VALID AND ACTIVE LICENSE?
YES
NO
19.
ARE YOU CONDUCTING A SEASONAL TYPE OF BUSINESS?
20. DO YOU EXPECT TO REMAIN IN BUSINESS FOR THE NEXT EIGHT (8) CALENDAR
QUARTERS?
YES
NO
IF YES, AND YOU ANSWER NO IN #23, DO NOT
YES
NO
IF NO, DO NOT SUBMIT, YOU ARE NOT ELIGIBLE FOR
SUBMIT, YOU ARE NOT ELIGIBLE FOR THIS
THIS COVERAGE. SEE INFORMATION SHEET ATTACHED.
COVERAGE. SEE INFORMATION SHEET ATTACHED.
21.
HOW MANY HOURS A DAY, WEEK, MONTH DO YOU PERFORM YOUR
22. DO YOU LIMIT THE NUMBER OF HOURS YOU PERFORM SERVICES?
SERVICES? INCLUDE ADMINISTRATIVE HOURS AND TIME SPENT
SOLICITING CUSTOMERS.
YES
NO
(IF YES, EXPLAIN IN #31)
DAY__________ WEEK_________ MONTH __________ (COMPLETE ALL THREE)
(HOURS)
(HOURS)
(HOURS)
*The disclosure of your Social Security number is mandatory under the Federal Tax Reform Act of 1976.
DE 1378A Rev. 39 (11-16) (INTERNET)
Page 1 of 4
CU
APPLICATION FOR UNEMPLOYMENT INSURANCE, STATE DISABILITY INSURANCE, AND PAID FAMILY LEAVE
ELECTIVE COVERAGE UNDER SECTION 708(a) OF THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE (CUIC)
Complete this application only if you meet the requirements as set forth
FOR DEPARTMENT USE ONLY
0B
in the attached Information Concerning Elective Coverage.
DIEC
-
-
APPROVED:
DENIED:
ACCOUNT #
NOTE: For assistance in completing this application, contact the nearest
EFFECTIVE DATE
SUBJECT
Employment Tax Office or call 888-745-3886. Upon completion of the
-
QUARTER
application, return to:
Attention: Analysis Resolution and Correspondence Organization
SEND FORMS
Employment Development Department
DE 2515, DE 3816DI, DE 1378DI
DE 3DI QTR(S)
PO Box 2068
Rancho Cordova, CA 95741-2068
DATE FORMS SENT:
APPROVED BY:
APPROVAL DATE:
PLEASE TYPE OR PRINT ALL INFORMATION CLEARLY.
ON-LINED BY:
ON-LINED DATE:
1.
SOCIAL SECURITY NUMBER*
2.
EMPLOYER ACCOUNT NUMBER
3.
GENDER
4. YEAR OF BIRTH
-
-
-
-
MALE
FEMALE
5. FIRST NAME
MIDDLE INITIAL
LAST NAME
6.
HAVE YOU APPLIED FOR ELECTIVE
COVERAGE BEFORE?
YES
NO
IF YES, ______
______
MO.
YR.
7. MAILING ADDRESS: NUMBER AND STREET OR PO BOX
CITY
ZIP CODE
8. BUSINESS NAME (IF ANY)
BUSINESS PHONE
(
)
9. BUSINESS ADDRESS: NUMBER AND STREET OR PO BOX
CITY
ZIP CODE
10.
EMAIL ADDRESS
11. WEBSITE
12.
DO YOU HAVE ANY EMPLOYEES?
IF YES, AND YOU ARE NOT REGISTERED WITH THE EMPLOYMENT DEVELOPMENT DEPARTMENT (EDD)
AS AN EMPLOYER, PLEASE EXPLAIN:
YES
NO
IF NO, SEE INSTRUCTIONS
13.
TYPE OF ORGANIZATION:
CORPORATION – DO NOT SUBMIT, CORPORATE OFFICERS ARE EMPLOYEES AND COVERED
GENERAL PARTNERSHIP (INCLUDES HUSBAND AND WIFE CO-OWNERS WHO ARE BOTH ACTIVE IN THE OPERATION AND
MANAGEMENT OF THE BUSINESS)
INDIVIDUAL
LIMITED PARTNERSHIP – ONLY GENERAL PARTNERS MAY APPLY
LIMITED LIABILITY PARTNERSHIP – ONLY GENERAL PARTNERS MAY APPLY
LIMITED LIABILITY COMPANY – PARTNERSHIP
LIMITED LIABILITY COMPANY – SOLE PROPRIETORSHIP MANAGING MEMBER
14. NAME(S) AND TITLE OF ALL PARTNERS AND MEMBERS (CONTINUE ON ANOTHER PAGE IF NECESSARY)
GENERAL PARTNERS/MEMBERS
SOCIAL SECURITY NUMBER*
LIMITED PARTNERS/MEMBERS
SOCIAL SECURITY NUMBER*
15.
NATURE OF BUSINESS:
CONTRACTING
MANUFACTURING
REPAIRING
RETAIL TRADE
SERVICE
WHOLESALE TRADE
OTHER (DESCRIBE):
16.
YOUR OCCUPATION/TITLE
17. DESCRIBE THE TYPE OF SERVICE, TYPE OF CONTRACTING, OR PRODUCT SOLD.
18.
IS A LICENSE OR PERMIT REQUIRED IN YOUR TRADE, BUSINESS OR OCCUPATION?
DO YOU POSSESS SUCH A
PROVIDE LICENSE/PERMIT NUMBER
YES
NO
IF YES, INDICATE TYPE OF LICENSE OR PERMIT REQUIRED:
VALID AND ACTIVE LICENSE?
YES
NO
19.
ARE YOU CONDUCTING A SEASONAL TYPE OF BUSINESS?
20. DO YOU EXPECT TO REMAIN IN BUSINESS FOR THE NEXT EIGHT (8) CALENDAR
QUARTERS?
YES
NO
IF YES, AND YOU ANSWER NO IN #23, DO NOT
YES
NO
IF NO, DO NOT SUBMIT, YOU ARE NOT ELIGIBLE FOR
SUBMIT, YOU ARE NOT ELIGIBLE FOR THIS
THIS COVERAGE. SEE INFORMATION SHEET ATTACHED.
COVERAGE. SEE INFORMATION SHEET ATTACHED.
21.
HOW MANY HOURS A DAY, WEEK, MONTH DO YOU PERFORM YOUR
22. DO YOU LIMIT THE NUMBER OF HOURS YOU PERFORM SERVICES?
SERVICES? INCLUDE ADMINISTRATIVE HOURS AND TIME SPENT
SOLICITING CUSTOMERS.
YES
NO
(IF YES, EXPLAIN IN #31)
DAY__________ WEEK_________ MONTH __________ (COMPLETE ALL THREE)
(HOURS)
(HOURS)
(HOURS)
*The disclosure of your Social Security number is mandatory under the Federal Tax Reform Act of 1976.
DE 1378A Rev. 39 (11-16) (INTERNET)
Page 1 of 4
CU
23.
DO YOU PERFORM SERVICES IN YOUR TRADE, BUSINESS, OR
IF NO, EXPLAIN.
OCCUPATION CONTINUOUSLY THROUGHOUT THE YEAR? (INCLUDE TIME
SPENT DOING OFFICE WORK, SOLICITING CUSTOMERS AND MAINTAINING
MACHINERY AND EQUIPMENT.)
YES
NO
24.
HOW LONG HAVE YOU HAD EMPLOYEES WORKING FOR YOU?
YEAR(S)
MONTH(S)
IF LESS THAN ONE YEAR, GIVE DATE FIRST EMPLOYEE WAS HIRED ____/____/_________
25.
IF YOU ARE SELF-EMPLOYED AND ALSO AN EMPLOYEE, DO YOU RECEIVE THE MAJOR PART OF YOUR INCOME FROM YOUR SELF-EMPLOYMENT?
YES
IF YES, WHAT PERCENTAGE?
%
NO
IF NO, EXPLAIN MAJOR SOURCE OF REMUNERATION.
26.
IF YOU WERE SELF-EMPLOYED DURING THE LAST TWO YEARS, WHAT
IF YOU HAVE NEVER FILED A SCHEDULE SE WITH THE IRS, DID YOU HAVE NET PROFIT
WAS YOUR NET PROFIT AS SHOWN ON YOUR IRS SCHEDULE SE, LINE 3?
IN EXCESS OF $4,600 LAST YEAR?
YES
NO
__________
$_____________
__________
$_____________
YEAR
NET PROFIT
YEAR
NET PROFIT
IF YOU HAVE BEEN IN BUSINESS FOR LESS THAN ONE YEAR, DID YOUR AVERAGE NET
PROFIT EXCEED $1,150 PER QUARTER?
YES
NO
IF YOU HAVE BEEN IN BUSINESS LESS THAN ONE QUARTER, DO YOU EXPECT YOUR
AVERAGE NET PROFIT TO EXCEED $1,150 PER QUARTER DURING THE FIRST YEAR IN
BUSINESS?
YES
NO
PLEASE SUBMIT COPIES OF YOUR IRS SCHEDULE SE FOR THE LAST TWO YEARS. IF ONLY IN BUSINESS ONE YEAR, ENTER ZERO FOR THE OTHER YEAR.
IF YOU ANSWERED NO TO ALL THREE QUESTIONS, DO NOT SUBMIT THIS APPLICATION UNTIL YOU EARN THE REQUIRED MINIMUM NET PROFIT IN YOUR TRADE,
BUSINESS, OR OCCUPATION.
27.
WERE YOU CONVICTED OF A MISDEMEANOR UNDER THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE DURING THE LAST EIGHT (8) CALENDAR QUARTERS?
(SEE ATTACHED INFORMATION SHEET)
YES
NO
DO YOU PRESENTLY HAVE AN ILLNESS, FAMILY CARE NEED, OR DISABILITY BONDING NEED WHICH PREVENTS YOU FROM CURRENTLY PERFORMING ALL YOUR
28.
REGULAR AND CUSTOMARY SERVICES IN CONNECTION WITH YOUR TRADE, BUSINESS OR OCCUPATION?
YES
NO
IF YES, WAIT TO SUBMIT UNTIL YOU ARE ABLE TO PERFORM ALL DUTIES.
29.
HAVE YOU BEEN DISABLED OR ON LEAVE TO BOND
IF YES, DID YOU FILE A CLAIM FOR BENEFITS?
WHEN DID YOU RESUME YOUR USUAL DUTIES?
WITH A NEW CHILD OR TO CARE FOR A SERIOUSLY
(DO NOT FILE THIS APPLICATION IF YOU ARE
ILL FAMILY MEMBER DURING THE LAST THREE
CURRENTLY DISABLED.) ______/______/_________
MONTHS?
YES
NO
YES
NO
30.
ON WHAT DATE DO YOU WISH ELECTIVE COVERAGE TO COMMENCE? KEEP IN MIND THAT THE COMMENCEMENT DATE OF AN ELECTIVE COVERAGE
AGREEMENT SHALL NOT BE PRIOR TO THE FIRST DAY OF THE CALENDAR QUARTER IN WHICH THE APPLICATION IS FILED, NOR LATER THAN THE FIRST DAY OF
THE FOLLOWING CALENDAR QUARTER.
FIRST DAY OF CURRENT QUARTER
DAY FIRST EMPLOYEE HIRED
FIRST DAY OF NEXT QUARTER
31.
ADDITIONAL INFORMATION (USE THIS SPACE TO MORE FULLY DISCUSS THE ABOVE QUESTIONS).
NOTE:
DO NOT SEND PAYMENT WITH THIS APPLICATION. IF APPROVED, YOU WILL BE NOTIFIED WHEN PAYMENT IS DUE. IF
YOU ARE ILLEGALLY IN THE UNITED STATES, YOU ARE NOT ELIGIBLE FOR BENEFITS AND ARE LIABLE TO REPAY
ANY BENEFITS PAID TO YOU. IF YOU NEED ADDITIONAL INFORMATION, PLEASE SEE PAGE 1 OF THIS FORM FOR
CONTACT INFORMATION.
I, the undersigned, declare that the statements made on this application are true and correct to my best knowledge and belief. I understand that providing false information will result in
denial or termination of coverage. I hereby elect and make application to have my services considered as employment subject to the California Unemployment Insurance Code (CUIC)
for Unemployment Insurance, State Disability Insurance, and Paid Family Leave. I hereby authorize the verification of any information provided by me on this application. I understand
that this election must remain in effect for two complete calendar years unless I no longer meet all of the eligibility requirements of Section 704 of the
CUIC
or I meet the conditions for
termination of coverage under Section 704.1 of the CUIC.
SIGNATURE OF APPLICANT
DATE
RESIDENCE ADDRESS (NUMBER AND STREET OR PO BOX, STREET, CITY, AND ZIP CODE)
RESIDENCE PHONE
(
)
APPLICATION MUST BE SIGNED TO BE VALID
DE 1378A Rev. 39 (11-16) (INTERNET)
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