Fillable Printable Notice Of Election To Make Voluntary Plan Applicable To All Employees (De 2520Cv)

Notice Of Election To Make Voluntary Plan Applicable To All Employees (De 2520Cv)

DE 2520 CV Rev. 5 (12-09) (INTERNET)Page 1 of 1 CU

NOTICE OF ELECTION TO MAKE VOLUNTARY PLAN APPLICABLE TO ALL EMPLOYEES

1. California Employer Identification Number: (the eight-digit number assigned when the

employer registered with the Employment Development Department [EDD]).

2. Employer’s legal name:

3. Employer’s address:

City, State, ZIP Code:

4. Pursuant to California Unemployment Insurance Code, Section 3257, the undersigned hereby gives

notice of election to make the voluntary plan applicable to all eligible employees except those who

reject the plan.

5. On there was a total of eligible employees in employment of whom

(DATE)

consented in writing or by electronic mail, at the employee’s option if electronic means

were available. (At least 85% of the eligible employees must have consented.) The plan will cover all

eligible

employees except those who reject it in writing or by electronic mail on and after .

(DATE)

6. As required by California Unemployment Insurance Code, Section 3257, a notice has been posted on

the premises for all eligible employees. The notice was also circulated on or before

for the attention of all employees who have not previously consented to the plan.(DATE)

7. After the date on which the plan is applicable to all employees, all new eligible employees will be

furnished a written statement setting forth the essential features of the plan along with a written

notice specifying their right to consent to or to reject the plan.

8. The consent records and the rejection records will be maintained for inspection by EDD for a period

of not less than four (4) years, or shorter period of time as approved by EDD.

9. I hereby certify that, to the best of my knowledge and belief, the foregoing statements, including any

accompanying statements, are true and correct.

If the Elector is an Employee Group If the Elector is the Employer

BY BY

(OWNER, PARTNER, OR OFFICER IF A CORPORATION)

TITLE TITLE

DATE DATE

Disability Insurance Voluntary Plan Group – P.O. Box 826880, MIC 29-VP – Sacramento CA 94280-0001