Fillable Printable Application For Approval Of Voluntary Plan For Successor (De 2041)

Application For Approval Of Voluntary Plan For Successor (De 2041)

APPLICATION FOR APPROVAL OF VOLUNTARY PLAN

FOR SUCCESSOR

Successor

Voluntary Plan No. Effective Date:

PREDECESSOR SUCCESSOR

CA Employer Account No. CA Employer Account No.

Commercial Commercial

Name: Name:

Address: Address:

The undersigned successor employer representative applies for continued approval of the Voluntary Plan,

which was previously approved by the Department and administered by the predecessor employing unit. It

is understood and agreed that with the continuance of approval of this Voluntary Plan the successor

assumes all obligations and liabilities of the predecessor.

(Signature of an Owner, Partner, or Officer

if a Corporation)

Typed name

Date Title

DE 2041 (5-05) (INTERNET) Page 1 of 2

A. Please indicate the reason for this Successor application:

New business (Subsidiary)

Purchased on-going business All Part Other

Change in form – (individual to corporation; partnership to corporation; merger; corporation to LLC, etc.)

B. Name, addr

ess, and phone number of the individual responsible for coordinating all activities of the

Voluntary Plan:

Name:

Address:

Phone:

E-mail Address (optional):

C. Name, addr

ess, and phone number of the individual who will process voluntary plan claims and disputed

coverage claim issues:

Name:

Address:

Phone:

E-mail Address (optional):

D. Number of employees eligible to be covered by the successor plan:

E. Estimated Voluntary Plan Taxable wages for current year:

F. To com

ply with the requirements of the Unemployment Insurance Code and Title 22, California code of

Regulations, security to guarantee payment of obligations of this Voluntary Plan will be deposited in the

following form:

Cash Deposit or Letter of Credit (specify: )

United States or State of California bearer bonds

Guarantee Bond of an admitted surety insurer

Rider to a Guarantee bond currently on deposit

for an affiliate voluntary plan employer

G. Include a

copy of the voluntary plan document.

DE 2041 (

5-05) (INTERNET) Page 2 of 2