Fillable Printable Work Sharing (Ws) Unemployment Insurance Plan Application (De 8686)
Fillable Printable Work Sharing (Ws) Unemployment Insurance Plan Application (De 8686)
Work Sharing (Ws) Unemployment Insurance Plan Application (De 8686)
1) Please select the box of the type of Work Sharin g plan you would like to file:
Note: To renew a plan a new application must be rec eived no later than 10 days after the expiration date of the prior plan.
If renewing, how many additional
Wor k Sharing Certifications
, DE 4581WS do you need? _____________
2) Employer Information
Name/DBA:
Business Type:
Employer Account Number: ____ ____ ____ – ____ ____ ____ ____ – ____
3) Employer Contact Information
Primary Contact
Alternate Contact
Name: Name:
Address: Address:
Phone: Phone:
4) Yes No Will the Work Shar ing occur in a different location than the a ddress provided above?
If yes, please pr ovide the alternate contact and location i nformation below:
Name (if different):
Name (if different):
Phone Number: Phone Number:
Address: Address:
5) Yes No Is your business/organization a public entity? Please check the appropriate box below.
6)
Yes No Your participation in the Work Sharing program is strictly confidential. Occasionall y the
Employment Development Department (EDD) receives requests for the names of companies that would
be willing to shar e their experiences with t his program. Are you willing to have your name and co ntact
information released for this purpose?
7) Fill in the table for the full-time and part-time workforc e who will be covered by the Work Sharing plan.
DE 8686 Rev. 20 (11-17) (INTERNET)
Page 1 of 5 CU
Work Sharing (WS) Unemployment Insurance Plan Application
Mail: Employment Development Department Work Sharing Program
PO Box 989060, West Sacramento, CA 95798-9007
Questions? 916-464-3343
New Renewal Expanded Coverage
Requested plan start date (must b e a Sunday): ____________________________________
City County State Federal Scho ol District Other (Specify) _________
a) Department/
Unit Name
b) Number of
employees in
Dept/Unit
c) Number of
employees in
Dept/Unit who will
participate in WS
d) Usual weekly hours
of employees in
affected Dept/Uni t
e) Estimated % of
weekly hours
reduced
1.
2.
3.
Total: ______ Total: ______ Total: ______ Total: ______
EDD USE ONLY
First Contac t Date: Effective Date:
WS EE: %: SIC: Union (Y/N) Layoff (Y/N)
8) Check the box below with the appropriate pay period cycle:
If your pay per iod is weekly or bi-weekly , select the payroll endin g day below:
9)
Yes No If you were not approved to part icipate in the Work Sharing program, would your
business lay off workers?
10) Estimate the number of employees who would need to be laid off if you were not participating in the
Work Sharing program: _________
11) Describe the circumstances requiring your use of the Work Sharing program:
12) How do you plan t o notify your employees of the Work S haring program?
13)
Yes No Will advance notice be given to the affected employees?
If not, please explain why advance not ice is not f easibl e:
14) Yes No Are any participating employees covered by a union/collective bargaining agreement?
If yes, the below section(s) must be completed:
15) Does your Work Sharing plan involve:
a.
Yes No At least two employees?
b.
Yes No At least 10 percent of your workforce or work unit(s)?
c.
Yes No At least a 10 percent reduction and no more than 60 percent in BOTH hours
worked and wages each week?
16)
Yes No Will a reduction in
health
benefits be scheduled to occur duri ng the duration of the
WS plan? If yes, answer the following que stion.
a.
Yes No If so, will those reductions be applied equally to all employees (including those
who are not participating in the WS plan)?
17)
Yes No Will a reduction in
retirement
benefits be scheduled to occur duri ng the duration of
the WS plan? If yes, answer the following question.
a.
Yes No If so, will those reductions be applied equally to all employees (including those
who are not participating in the WS plan)?
DE 8686 Rev. 20 (11-17) (INTERNET)
Page 2 of 5
Work Sharing (WS) Unemployment Insurance Plan Application
Mail: Employment Development Department Work Sharing Program
PO Box 989060, West Sacramento, CA 95798-9007
Questions? 916-464-3343
Memo/Letter Email Staff Meeting Other (Specify) ____________________
Union Nam e: Union Local Number: Phone Number:
Name of Aut ho rized Union Representative: Position Ti tle:
Authorized Union Representative Signature: Date:
Mon Tues Wed Thur Fri Sat Sun
Weekly Bi-weekly Monthly Other (Specify) ______________________
Union Nam e: Union Local Number: Phone Number:
Name of Aut ho rized Union Representative: Position Ti tle:
Authorized Union Representative Signature: Date:
By signing this application, we understand and certify the following is true and correct:
1. We understand that by participating in the WS program our reserve account will be charged in the
usual manner or may have an adverse effect on our tax rate.
2. We understand that if we are a participating reimbursable employer, we will be billed quarterly for the
cost of benefits paid.
3. We understand that we are not to utilize the WS program for total layoffs during the holiday weeks.
4. We understand that a holiday cannot be used as a WS day unless the employee(s) in the same
posi tion performed services (and was paid for those services) as a part of a regular work week, dur ing
the 12 months prior to the employer’s parti cipation i n the WS program.
5. We understand that any employee on the WS program must have worked at le ast one normal work
week with no reductions prior to the issuance of certification forms for benefit payments.
6. We understand that if employees are attached to a school district and/or non-profit entity that we wil l
provide dates the em ployee(s) are between successive academic terms/recess periods.
7. We understand that the plan approved by the EDD shall expire 12 months after its effective date.
8. We understand that we must continue to provide health and retirement benefits under the same terms
and conditions as when the affec ted employ ees worked his/her usual weekly hours, un less health/
retirement benefits change for all employees (including employees not participating in the WS plan).
9. We understand that we must pro vide the weekly percentage of reductions in hours and wages for each
participating employee, and we must furnish all reports and information as requested by the EDD to
monitor and review our WS plan.
10. We understand that we must notify the EDD immediatel y if there are any changes to the information
on this plan application, and that we must submit the specific changes in writing for review and
approval.
11. We understand that leased or temporary service empl oyees that are provided by another employer or
that we provide to other employers, cannot be cove red under the WS plan.
12. We understand that par ticipating in the WS program is consistent with the empl oyer’s o bligation under
applicable federal and state laws.
DE 8686 Rev. 20 (11-17) (INTERNET)
Page 3 of 5
Work Sharing (WS) Unemployment Insurance Plan Application
Mail: Employment Development Department Work Sharing Program
PO Box 989060, West Sacramento, CA 95798-9007
Questions? 916-464-3343
HOLIDAY OPEN CLOSED COMMENTS
New Year's Eve
New Year's Day (Observed)
Martin Luther King Jr. Day
Lincoln's Birthday
Washington's Birthday
President's D ay
Cesar Chavez Day
Good Friday
Memorial Day
July 4
th
Labor Day
Columbus Day
Veterans Day
Thanksgiving
Day After Thanksgiving
Christmas Eve
Christmas Day (Observed)
Other Holidays: Please list below
I have provided the information on this form so that our employees may participate in the Work Sharing Unemployment
Insurance program. I understand failure to provide correct information, in accordance with this certification and in
accordance with the provisions of the California Unemployment Insurance Code (CUIC), could result in a denial or
cancellation of this plan. I certify that I agree to all Work Sharing terms per Section 1279.5 of the CUIC. If signing this
form electronically, I understand and acknowledge that this electronic signature has the same meaning and validity as
m y handwritten signature. I further attest that I have signature authorit y wit h the named employer.
*If a private business, below signature must be of corporate officer, sole proprietor, or general partner.
*If a public entity, below signature must be of executive officer or person wit h authorization.
Authorized Signature:
Title:
Print Name: Date:
Work Sharing Employer’s Holiday Schedule
A holiday schedule is necessary to process employee’s WS payments. Please indicate which holidays your company
was open/closed during the 12 months prior to the start of your WS plan.
DE 8686 Rev. 20 (11-17) (INTERNET)
Page 4 of 5
Work Sharing (WS) Unemployment Insurance Plan Application
Mail: Employment Development Department Work Sharing Program
PO Box 989060, West Sacramento, CA 95798-9007
Questions? 916-464-3343
Employer Account Number: ____ ____ ____ – ____ ____ ____ ____ – ____
Please complete the WS Employee Participant Roster on page 5 and ensure the number
of employees listed matches the total number of employees listed on page 1, question 7c.
Employee’s Full Name Employee’s
Full SSN
Depa rtment/
Work Unit
Name
Indicate if WS e mployee
is a Corporate Officer or
Sole or Major stockholder
(Yes/No)
If applicable, enter
title/role of Corporate
Officer or Sole or
Major stockholder
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
Work Sharing Employee Participant Roster
*Employee Participant Roster must match the number indicated on Question #7c on page 1 of 5.
additional space is needed. The WS plan cannot be approved without a WS Employee Participant Roster.
DE 8686 Rev. 20 (11-17) (INTERNET) Page 5 of 5
Work Sharing (WS) Unemployment Insurance Plan Application
Mail: Employment Development Department Work Sharing Program
PO Box 989060, West Sacramento, CA 95798-9007
Questions? 916-464-3343
Employer Account Number: ____ ____ ____ – ____ ____ ____ ____ – ____
NOTE: A complete list of employees participating must be included with your application. Copy this page if
