Fillable Printable Application For Elective Coverage Of Sdi Only Local Public Entities And Indian Tribes (De 1378M)

Application For Elective Coverage Of Sdi Only Local Public Entities And Indian Tribes (De 1378M)

DE 1378M Rev. 11 (8-16) (INTERNET) Page 1 of 2 CU

APPLICATION FOR ELECTIVE COVERAGE OF STATE DISABILITY INSURANCE* ONLY

LOCAL PUBLIC ENTITIES AND INDIAN TRIBES

Reference: Section 709 of the California Unemployment

Insurance Code (CUIC)

MPORTANT

o not complete this form unless you wish to apply for

State Disability Insurance only under Section 709 for

ALL of your employees (excluding elected officials and

appointees by the Governor). Coverage under this

section of the CUIC does not make provision for

Unemployment Insurance benefits.

FOR DEPARTMENT USE ONLY

EMPLOYER ACCOUNT NUMBER STATISTICAL CODE

EFFECTIVE DATE DATE EMPLOYER NOTIFIED

APPROVED BY

DATE APROVED

SEND

NUMBER OF EMPLOYEES

PLEASE TYPE OR PRINT

1. Name of Government Entity or Indian Tribe

Business Phone

2. Business Address (Number, Street, City, County, State, ZIP Code)

3. Mailing Address (Number, Street, City, County, State, ZIP Code)

4. Type of Local Public Entity

County City Indian Tribe Other (Specify)

5. Law under which agency was established: (Complete a, b, c, or d; does not apply to Indian Tribes.)

a. California Tax Law

Title of Act

Number

Date

b. California Codes

Title of Code

Division

Part

Chapter

c. Charter

Title of Charter

Date

d. Ordinance

Title of Ordinance

Date

6. Members of governing body of local public entity or Indian Tribe, such as Board of Supervisors, City Council, District

Directors, Tribal Council, etc.

Name Title Residence Address Phone

Social Security

Number

NOTE: If your application is approved, the elective coverage agreement will be subject to all of the requirements and

conditions outlined in Information Concerning Elective Coverage Under Section 709 of the California

Unemployment Insurance Code (CUIC), DE 1378L. Please retain your copy of the DE 1378L for reference.

* Includes Paid Family Leave (PFL).

DE 1378M Rev. 11 (8-16) (INTERNET) Page 2 of 2 CU

7. Appointive Positions: (These persons are eligible for coverage unless appointed by the Governor.)

Title of Position

Number of

Positions in This

Category

By Whom Appointed

Number of

Persons Desiring

Coverage

8. Total number of employees to be covered, excluding elected officers and those appointed by the Governor:

9. 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

NOTE: Deductions should not be made from your employee's wages for the purpose of paying employee contributions

required under the CUIC until your election is approved.

Attach a copy of the resolution in which the governing body described in Item 6 approved the filing of an application for

elective coverage under Section 709 of the CUIC.

The governmental or tribal entity described in Item 1 hereby files its application under Section 709 of the CUIC to become

an employer subject to the CUIC. It is understood that upon approval of the election by the Director, the governmental or

tribal entity will be an employer subject to the CUIC for State Disability Insurance purposes only to the same extent as

other employers as of the date specified in the approval, and will remain a subject employer for at least two complete

calendar years. Thereafter, this election may be terminated as provided by the CUIC.

I certify that this application has been examined by me, and to the best of my knowledge and belief, it is true and correct

and made in good faith under the provisions of the CUIC.

This certificate must be signed by one or more of the persons listed under Item 6.

Signature Title Date

Return completed application to:

Employment Development Department

Analysis Resolution and Correspondence Organization

PO Box 2068

Rancho Cordova, CA 95741-2068

Questions may be directed to the above address or call 888-745-3886.

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.