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Fillable Printable De 2520Au

Fillable Printable De 2520Au

De 2520Au

De 2520Au

DE 2520AU (3-11) (INTERNET) Page 1 of 3 CU
APPLICATION TO PARTICIPATE IN A SMALL-BUSINESS THIRD-PARTY
ADMINISTRATOR (SBTPA) ADMINISTERED VOLUNTARY PL AN FOR UNEMPL OYMENT
COMPENSATIO N DISABILITY (UCD) BENEFITS
EMPLOYER INFORMATION
Items 1 through 14 to be completed by the employer:
1. Effective date of this voluntary plan:
2. California Employer Account Number (EAN): _______ (this is the 8-digit number that the
Employment Development Department (EDD) assigned when the employer registered with the
EDD).
3. Employer’s legal name:
4. Other business name(s) used by the employer in California:
5. Employer’s business address:
City, State, Zip Code:
6. Nature of
employer’s business; for example, type of product manufactured or service provided:
7. Employee appoi
nted to manage the administration of the voluntary plan:
Name:
Title:
Address:
City, State, Zip Code:
Telephone:
( )
E-mail address:
ELECTION INFORMATION
8. Total num
ber of employees eligible to be covered by the voluntary plan:
a
s of
.
Number Da
te
9. Total number of employees who have consented, in writing or by electronic mail, to be covered by
the voluntary plan: a
s of
.
Number
Date
10. Election conducted between and .
Date
Date
DE 2520AU (3-11) (INTERNET) Page 2 of 3
REQUIRED DOCUMENTS
Items 11 through 14 must be submitted to the SBTPA with this application:
11. Copies
of all informational documents distributed to your employees to secure their consent to
the voluntary plan.
12. Copy
of the SBTPA Self-Insur ed Voluntary Plan (SIVP) document previously approved by the
Direct o r of the EDD.
13. Copy
of the statement of coverage, if one used, that was given to your employees.
14. Copy
of the enrollment form used to secure your employees’ consent to the plan; requesting
their signature, date of consent, printed or typed name, and Social Security Number.
SBTPA INFORMATI ON
Items 15 through 17 to be completed by the SBTPA:
15. SBTPA Commercial Nam e :
Address:
City, State, Zip Code:
Telephone:
( )
16. SBTPA California Employer Account Number (EAN): (this is the 8-digit number
that was assigned when the company registered with EDD as a California employer).
17. SBTPA Voluntary Plan Number:
(this is
the 6-digit number that the EDD assigned
to the SBTPA granting it the authority
to act as a third-party administrator to small businesses
electing to provide voluntary plan coverage to their employees).
CERTIFICATION
By signing below, the employer and the SBTPA:
A. Subm
it this application for approval of a voluntary plan under the Califor nia Unemployment
Insurance Code (hereinafter identified as “Code”) and Title 22, California Code of Regulations
(hereinafter identified as “Regulations”).
B. Agree to operate the voluntary plan in conformity with the Code and Regulations and in
accordance with the provisions of the SBTPA voluntary plan provisional document provided to
the EDD Voluntary Plan Administration Unit.
C. Ag
ree to pay any assessments which are levied in conformity with the Code and Regulations
that directly relate to the voluntary plan.
D. Certify that all eligible employees were g iven the opportunity to elect or reject coverage under
the plan and that a majority of the eligible employees consented, in writing or by electronic
mail, to coverage under the plan.
DE 2520AU (3-11) (INTERNET) Page 3 of 3
E. Agree to offer the plan to all eligible new employees, and will maintain available for inspection by
Department representatives the signed consents of all employees for a period of not less than five
years.
F. Agree to post, upon request of the Director of the EDD, additional secur ity in an amount
determined by the Director to be adequat e to pay this voluntary plan’s obligations should the
subaccount created by this application or the financial security provided by the SBTPA be
inadequate to meet the obligations of this voluntary plan.
G. Agree to provide written notice to the Director of the EDD not less than 30 days prior to the date of
withdrawal in the event that a decision is reached to terminate participation in the SBTPA
voluntary plan.
H. Certify that the foregoing statements, including any accompanying statements, are to the best of
our knowledge and belief true and correct.
Employer Certification SBTPA Certification:
By _______________________________ By
(Must be signed by Owner, Partner, Authorized Representative
or Offic er if a Corporation)
______________________________
Print Name and Title Print Name and Title
______________________________ __________________________________
Date Date
Mail completed application to: EDD, Disability Insurance Branch
Voluntary Plan Administration Unit, MIC 29 VP
PO Box 826880
Sacramento CA 94280-0001
If you have questions or need assistanc e completing this form, please call (916) 653-6839.
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