Form DE1378DI "Application for Disability Insurance Elective Coverage (Diec)" - California

What Is Form DE1378DI?

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;

Download a fillable version of Form DE1378DI by clicking the link below or browse more documents and templates provided by the California Employment Development Department.

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Download Form DE1378DI "Application for Disability Insurance Elective Coverage (Diec)" - California

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Application For Disability Insurance Elective Coverage (DIEC)
For Department Use Only
Complete this application only if you meet the requirements as set
forth in the attached Information Concerning Elective Coverage.
DIEC
DIEC
Approved:
708(b)
708.5
Account #
NOTE: For assistance in completing this application, contact
Effective Date:
Subject
the nearest Employment Tax Office or call 888-745-3886.
Quarter
Upon completion of this application, return to:
Attention: Analysis Resolution and Correspondence Organization
Send Forms
Employment Development Department
DE 2515, DE 3816DI
DE 3DI Qtr(s) __________________________
PO Box 2068
Date Forms Sent:
Approved By:
Approval Date:
Rancho Cordova, CA 95741-2068
Rev/Reg By:
Rev/Reg Date:
Please type or print all information clearly.
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
Corporation - Do not submit, corporate officers are employees and covered under the State Disability Insurance Program.
13. Type of Organization:
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 partner 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/Managing 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?
Yes
No
Do you possess such a valid and active
Provide License/Permit Number
If yes, indicate type of license or permit required:
license?
Yes
No
20. Do you expect to remain in business for the next eight (8) calendar quarters?
19. Are you conducting a seasonal type of business?
YES
NO
If yes, do not submit. You are not eligible for this coverage. See information sheet attached.
Yes
No
If no, do not submit. You are not eligible for this coverage.
See information sheet attached.
21. Do you perform services in your trade, business, or occupation continuously throughout the year?
If no, explain.
(include time spent doing office work, soliciting customers, and maintaining machinery and
equipment.)
Yes
No
*The disclosure of your Social Security number is mandatory under the Federal Tax Reform Act of 1976.
DE 1378DI Rev. 44 (11-16) (INTERNET)
Page 1 of 4
CU
Application For Disability Insurance Elective Coverage (DIEC)
For Department Use Only
Complete this application only if you meet the requirements as set
forth in the attached Information Concerning Elective Coverage.
DIEC
DIEC
Approved:
708(b)
708.5
Account #
NOTE: For assistance in completing this application, contact
Effective Date:
Subject
the nearest Employment Tax Office or call 888-745-3886.
Quarter
Upon completion of this application, return to:
Attention: Analysis Resolution and Correspondence Organization
Send Forms
Employment Development Department
DE 2515, DE 3816DI
DE 3DI Qtr(s) __________________________
PO Box 2068
Date Forms Sent:
Approved By:
Approval Date:
Rancho Cordova, CA 95741-2068
Rev/Reg By:
Rev/Reg Date:
Please type or print all information clearly.
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
Corporation - Do not submit, corporate officers are employees and covered under the State Disability Insurance Program.
13. Type of Organization:
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 partner 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/Managing 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?
Yes
No
Do you possess such a valid and active
Provide License/Permit Number
If yes, indicate type of license or permit required:
license?
Yes
No
20. Do you expect to remain in business for the next eight (8) calendar quarters?
19. Are you conducting a seasonal type of business?
YES
NO
If yes, do not submit. You are not eligible for this coverage. See information sheet attached.
Yes
No
If no, do not submit. You are not eligible for this coverage.
See information sheet attached.
21. Do you perform services in your trade, business, or occupation continuously throughout the year?
If no, explain.
(include time spent doing office work, soliciting customers, and maintaining machinery and
equipment.)
Yes
No
*The disclosure of your Social Security number is mandatory under the Federal Tax Reform Act of 1976.
DE 1378DI Rev. 44 (11-16) (INTERNET)
Page 1 of 4
CU
22. How long have you performed services as a self-employed individual, partner, or member? ________ Year(s) _______ Month(s)
If less than 1 year, give date business started _______ / _______ / _______
23. Do you perform your services under a written contract or agreement?
Yes (Please attach copy) or (Explain oral agreement in #32)
No
24. Is the major part of your service(s) performed for any specific firm or individual?
If yes, identify the business name and address.
Yes
No
25. Have you previously worked as an employee for a firm for which you are now performing services?
If yes, explain services performed as an employee.
Yes
No
26. 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.
27. If you were self-employed during the last two years, what was your net profit as shown on your IRS
If you have never filed a schedule se with the IRS, did you have net profit in excess of $4,600
schedule SE, line 3?
last year?
Yes
No
$
$
If you have been in business for less than one year, did your average net profit exceed $1,150
Year
Net Profit
Year
Net Profit
per quarter?
Yes
No
If you just started a business, do you expect to earn a net profit of at least $1,150 per quarter
through the end of the year?
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.
28. Were you convicted of a misdemeanor under the California Unemployment Insurance Code
(CUIC)
during the last eight (8) calendar quarters? (See attached information sheet)
Yes
No
29. Do you presently have an illness or disability which prevents you from currently performing all your regular and customary services in connection with your trade, business, or occupation? (Do not file
application if you are currently disabled.)
Yes
No
If yes, did you file a claim for benefits?
Yes
No
30. Have you been disabled or off work to bond with a new child or to
If yes, did you file a claim for benefits?
When did you resume your usual duties?
care for a seriously ill family member during the last three months?
Yes
No
Yes
No
_______ / _______ / _______
31. 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
First Day of Next Quarter
32. Additional Information (Use this space to more fully discuss the above questions)
DECLARATION
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
CUIC
for State Disability
Insurance only. 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, City, and ZIP Code)
Residence Phone
(
)
Application must be signed to be valid.
DE 1378DI Rev. 44 (11-16) (INTERNET)
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