Login

Fillable Printable Application For Diec (De 1378Di)

Fillable Printable Application For Diec (De 1378Di)

Application For Diec (De 1378Di)

Application For Diec (De 1378Di)

DE 1378DI Rev. 44 (11-16)(INTERNET)Page 1 of4 CU
Application For Disability Insurance Elective Coverage(DIEC)
Complete this application only if you meet the requirements as set
forth in the attached Information Concerning Elective Coverage.
NOTE: Forassistance in completingthis application, contact
the nearest Employment Tax Officeor call 888-745-3886.
Upon completion of thisapplication, return to:
Attention: Analysis Resolution and Correspondence Organization
Employment Development Department
POBox 2068
Rancho Cordova, CA 95741-2068
Please type or print all information clearly.
For Department Use Only
DIEC
Approved: 708(b) 708.5
DIEC
Account #
Effective Date:
Subject
Quarter
Send Forms
DE 2515, DE 3816DI DE 3DI Qtr(s) __________________________
Date Forms Sent:
Approved By:
Approval Date:
Rev/Reg By:
Rev/Reg Date:
Social Security Number*
2.
Employer Account Number
3.Gender4. Year of Birth
MaleFemale
5. First Name
Middle InitialLast Name
6. Have you applied for electivecoverage
before?Yes No
If yes,
Mo.
Yr.
7. Mailing Address: Number and Street orPO Box
City
ZIP Code
8. Business Name: (If Any)
Business Phone
( )
9. Business Address: Number and Street orPO Box
City
ZIP Code
10. EmailAddress:
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
13. Type of Organization: Corporation - Do notsubmit, corporate officers are employees and covered under theState Disability InsuranceProgram.
General Partnership (includes husband and wife co-owners who are both active in the operation and management ofthe business).
IndividualLimited Partnership - only general partner may apply
Limited Liability Partnershiponly general partners may apply
Limited Liability Company – Partnership
Limited Liability CompanySole Proprietorship Managing Member
14. Name(s) and Title of All Partners and Members (continue on another page if necessary)
General Partners/MembersSocial Security Number* Limited Partners/Managing MembersSocial Security Number*
15. Nature of Business:
ContractingManufacturingRepairing
Retail TradeService Wholesale TradeOther (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 validand active
Provide License/Permit Number
If yes, indicate type of license or permit required:
license?
Yes No
19. Are you conducting a seasonal type of business?YES NO
If yes, do not submit. You are not eligible for thiscoverage. See information sheet attached.
20. Do you expect to remain in business for the next eight (8) calendarquarters?
Yes No If no, do not submit. You are not eligible forthis coverage.
See information sheet attached.
21. Do you perform services in your trade, business, or occupationcontinuously throughout the year?
(include time spent doing office work, soliciting customers, and maintaining machinery and
equipment.)
If no, explain.
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 2 of4 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 orindividual?
If yes, identify the business name and address.
Yes No
25.Have you previously worked as an employee for a firm for which you arenow 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?
YesIf yes, what percentage?_________%
NoIf no, explain major source of remuneration.
27.If you were self-employed during the last two years, what was your netprofit as shown on your IRS
schedule SE, line 3?
If you have never filed aschedule se with the IRS, did you have netprofit inexcess of $4,600
last year?
Yes No
$
$
YearNet ProfitYearNet Profit
If you have been in business for less than one year, did your average netprofit exceed $1,150
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 threequestions, do notsubmit this application until you earn the required minimum net profit in your trade, business, oroccupation.
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 inconnection with yourtrade, business, or occupation? (Do not file
application if you are currently disabled.)YesNo
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
care for a seriously ill family member during the last three months?
If yes, did you file a claim for benefits?
When did you resume your usual duties?
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 beprior to the first day ofthe calendar quarterin
which the application is filed, nor later than the first day of the following calendar quarter.
First Day of Current QuarterFirstDay 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 CUICfor StateDisability
Insuranceonly. I hereby authorize the verification of any information provided by me on this application. I understand that this electionmustremain in effect for twocomplete
calendaryears unless I no longer meet all of the eligibility requirements of Section704 of the CUIC or I meet the conditions for termination of coverage under Section704.1 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 tobe valid.
DE 1378DI Rev. 44 (11-16)(INTERNET)Page 3 of4 CU
Information ConcerningDIEC* UnderSections708(b) and708.5 oftheCUIC
Do not send any payment with this application.Contributions are not payable in advance.
You will receive a written notice of the approval or denial of your application.
If your elective coverage agreement is approved, instructions will be sent to you for filing your returns and paying the premiums
due.Your agreement is subject to the requirements and conditions outlined below.
Please retain this page for reference.
Persons Eligible to Elect Coverage
Section 708(b) of the CUIC provides that an individual who is an employer under Section 675 of the CUIC, or two or more
individuals who have so qualified, may elect coverage. Each individual who applies must provide evidence of an annual net
profit of at least $4,600 or average $1,150 per quarter if in business for less than one year.
Section 708.5 of the CUICprovides that self-employed individuals who receive the major portion of their remuneration from
the trade,business, or occupation in which they are self-employed, may elect coverage. Annual net profit must be at least
$4,600 or average $1,150 per quarter if in business for less than one year.
Soleproprietors, general partners, managing members of Limited Liability Companies (LLC) treated as sole-proprietors for
federal income tax purposes, and members of LLCs treated as partnerships for federal income tax reporting purposesare
eligible to apply for coverage. It is not required that all active general partners or membersbe included in the election.An active
general partnership also includes a husband and wife co-ownership in which both spouses are active in the operation and
management of the business.Limited partners and corporate officers are considered to be employees subject to the compulsory
provisions of the CUIC, the same as all other employees, and are not eligible to elect self-coverage.
Conditions for Denial of Coverage
Section 704 of the CUIC provides that an election under Section 708(b) or Section 708.5 of the CUIC shall not be approved if it
is found that any of the following conditions exist:
(a)The self-employed individual is currently unable to perform his or her regular and customary work due to injury or illness.
(b)The employing unit or self-employed individual is notnormally and continuously engaged in a regular trade, business, or
occupation.
(c)The employing unit or self-employed individual intends to discontinue the regular trade, business, or occupation within
eight calendar quarters.
(d)The regular trade, business, or occupation of the employing unit or self-employed individual is seasonal in its operations.
(e)The major portion of the self-employedindividual’sremuneration is not derived from his or her trade, business, or
occupation.
(f)The self-employed individual is unable to provide a copy of his or her Internal Revenue Services (IRS) Schedule SE for
the preceding year showing a net profit of at least $4,600 or to certify to an average net profit of at least $1,150 per
quarter since becoming self-employed or for the preceding four quarters, whichever period is less.
(g)The employing unit or self-employed individual has failed to make a return or to pay contributions within the time required,
pursuant to the CUIC and there is an unpaid amount of contributions owing by the employing unit or self-employed
individual.
(h)Section 704(h) (1) and (2) of the CUIC: (1) A prior elective coverage agreement entered into pursuant to Section708or
708.5 has beenterminated by the department under Section 704.1 or by means of a written application for termination as
required by this division, and the individual has not completed a waiting period of 18 consecutive months from the date of
termination. (2) The waiting period for reinstatement to the elective coverage program may be waived for any individual
who becomes eligible for coverage after being terminated under paragraph (1), (2), (4), or (5) of subdivision (a) of
Section704.1, upon receipt by the department of an application for coverage to be effective the first day of the quarter in
which the application is received.
(i)The employing unit or any officer or agent of or person having charge of the affairs of the employing unit, or the
self-employed individual has been convicted within the preceding eight consecutive calendar quarters of any violation
under Chapter 10(commencing with Section 2101of the CUIC). For the purposes of this subdivision, a plea or verdict of
*Includes Paid Family Leave
DE 1378DI Rev. 44 (11-16)(INTERNET)Page 4 of4 CU
guilty or a conviction following a plea of nolo contendere is deemed to be a conviction irrespective of whether an order
granting probation or other order is made suspending the imposition of the sentence or whether sentence is imposed for
execution thereof is suspended.
(j)For purposes of this section, IRS ScheduleSE is defined as IRS Form 1040 Schedule SE, or in the case of statutory
employees under the Internal Revenue Code, it shall be defined as IRS Form 1040Schedule C, or the CaliforniaResident
Income Tax Return,DE540,when accompanied by IRSForm W-2.
Elections filed under Section 708.5 of the CUIC are subject to verification by the Employment Development Department (EDD)
that the individual is in fact self-employed rather than an employee of another individual or firm.If an individual filing an
application for coverage under Section708.5 of the CUIC as a self-employed individual has any knowledge of a prior ruling
issued by the EDDconcerning hisor her status, reference to such ruling should be made on the applicationform and, if
possible, a copy of the ruling attached.
Cost of Coverage
You will receive notification of the following year’s premium rate, reportable “income credits,” and premiums payable with your
fourth quarter premium notice. You may estimate the cost of coverage using formDisability Insurance Elective Coverage
(DIEC)Rate Notice and Instructions for Computing Annual Premiums,DE 3DI-I, or call the phone number shown on the front of
your application for assistance.
Quarterly Report Required
The Quarterly Premium Notice for Disability Insurance Elective Coverage,DE 3DI, must be filed each quarter whether or not
premiums are due.This notice is normally mailed by the last day of the calendar quarter.The DE 3DIand premiums are due on
the first day of the following calendar quarter and become delinquent if not paid on or before the last day of that month.Failure
to receive a DE 3DI doesnot relieve you of the responsibility to pay your premiums on time.Submitting the DE 3DI with
disability information is not a claim for benefits.Contact your local Disability Insurance benefit office for claim information.
Reportable Compensation
Any adjustment of the reportable income credits and premiums due to State Disability Insurance (SDI) or Paid Family
Leave (PFL) must be noted on the DE 3DI.If you have any questions regarding computing or adjusting the reportable
income creditsand premiums, contact your local Employment Tax Office or call the Analysis Resolution and
Correspondence Organizationat 888-745-3886.
Benefit Eligibility
The EDDdetermines eligibility for SDI and PFL benefits pursuant to the CUIC and authorized regulations. Generally, a
minimum of several months must elapse from the commencement date of coverage before a valid claim may be filed
based solely on income credits reportable under your election.Eligibility is dependent on a number of factors including:
proof of a claimant’s eligibility, filing of a timely claim for benefits, and filing and payment of all required reports and amounts
due. Weekly SDI or PFL benefits are payable under elective coverage regardless of whether the claimant continues to receive
any compensation from hisor her business.
The SDI benefits cover both work related and non-occupational injuries and illness. For SDI benefit information, see the
pamphlet Disability Insurance Provisions,DE2515, or contact your local DI field office at 800-480-3287.
Cancellation/Termination of Elective Coverage
A participant may cancel hisor her elective coverage agreement as of January 1 of any calendar year, and only if the
agreement has been in effect for two complete calendar years, by filing a letter with the EDDrequesting termination on or
before January 31 of that year.
The EDDmay terminate your elective coverage agreement if it is found that any of the "Conditions for Denial of
Coverage" exist or you meet one of the followingconditions for termination of coverage by the EDDfound in Section
704.1of the CUIC:
Section 704.1(a)(5):The self-employed individual reports a net profit of less than$4,600 on his or her IRS Service
Schedule SE for a third consecutive year.
Section 704.1(a)(7): The employing unit or self-employed individual, or a representative thereof, is found by the
director to have filed a false statement in order to be considered eligible for elective coverage.
You will be given written notification of the EDD’stermination of your elective coverage agreement and will have 30
days to file a Petition for Review of the termination of elective coverage.The termination shall not affect the liability of the
self-employed individual for any premiums due, owing or unpaid to the EDD. Termination bythe EDDmay affect your ability to
draw SDIbenefits.
The EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Requests for
services, aids, and/or alternate formats need to be made by calling 888-745-3886 (voice) or TTY 800-547-9565.
Login to HandyPDF
Tips: Editig or filling the file you need via PC is much more easier!
By logging in, you indicate that you have read and agree our Terms and Privacy Policy.