APPLICATION TO ELECT COVERAGE UNDER 
          DEPARTMENT OF LABOR & INDUSTRY                                                                                 THE PENNSYLVANIA UNEMPLOYMENT                                                           
          OFFICE OF UNEMPLOYMENT COMPENSATION TAX SERVICES 
                                                                                                                            COMPENSATION LAW FOR SERVICES 
                                                                                                  PERFORMED ENTIRELY IN ANOTHER STATE

After reading page 2 of this form, prepare the application in triplicate and forward to: Department of Labor & Industry, Office of UC Tax                                                                         
Services, PO Box 68568, Harrisburg, PA 17106-8568. All items must be completed and a copy of the waiver from the state in which the                                                                                 
employees work must be attached. You will be informed of approval or disapproval of application. 

 Employer’s Business Name:                                                                                                                                     PA UC Acct. No.:                                 
Address: 

Check type of entity: 
G Individual                  G Partnership                  G Association                                               G Other (identify)  
G Domestic Corporation (Pennsylvania)                                                                                        Date of Incorporation:    
G Foreign Corporation                       State of Incorporation:                                                         Date of PA Certificate of Authority:           
G Limited Liability Company      State Where Chartered:  

                                                                                                                                                       STATE FROM           STATE 
                                                                                                                                                       WHICH                IN WHICH 
                                                                                     SOCIAL                                       STATE OF             EMPLOYEE’S           SERVICE IS 
                                                                                     NUMBER                                                                                 
                 EMPLOYEE’S NAME                                                     SECURITY                                    RESIDENCE             WORK IS              PERFORMED  
                                                                                                                                                       CONTROLLED 

DATE YOU WISH VOLUNTARY ELECTION TO BECOME EFFECTIVE 
I hereby file application to extend coverage, under the Pennsylvania Unemployment Compensation Law, as provided in Article 1, Section 4. It is 
understood that this application is made fully subject to the regulation covering “elections.” I certify that the statements and information above 
are true and correct. 

                                                                                                  Signature 

Date                                                                                              Title 

                                                                                     FOR DEPARTMENT USE ONLY 

Received                                                                       Employer Notified                                                          PA UC Acct. No. 

Examined By                                                                Effective 
G APPROVED                   G DISAPPROVED 

EFFECTIVE DATE                                                                                                        By 

UC-8A REV 09-21 (Page 1) 

Article I, of 4 Pennsylvaniathe  Section CompensationUnemployment Law defines “State” as any the fifty statesof one the United States,of     
Puerto  Rico, Virgin  Islands   and  of  Columbia. District  the  also It  provides  that  an  to  the  Pennsylvania employer  subject  Unemployment    
Compensation Law may include to elect the to servicesAct, the  within subject “employment”, term employees with its by performed or his     
respect to which no contributions are required and paid under an unemployment compensation law of any other state, (a) if the employee(s),  
included in such election, maintain a domicile within this commonwealth and the services of such employee(s) are performed entirely without  
this commonwealth, or (b) if the employee(s) included in the election maintains no domicile within this commonwealth but the services of such  
employee(s) are (A) performed without this commonwealth and (B) are directed from this commonwealth. 

WAIVER OF COVERAGE.  Every employer who is requesting voluntary coverage under the Pennsylvania Unemployment Compensation Law shall  
obtain a waiver of coverage from the state in which the employees work, certifying that the services are not covered. A copy of this waiver shall  
be attached to the application; otherwise it will be disapproved. 

EFFECTIVE DATE OF ELECTION. Any election approved by the department shall become effective at the beginning of a calendar quarter. In no  
event shall the department approve an election for an effective date prior to January 1 of the previous calendar year, unless, in the opinion of  
the administrators, an election dated prior to the date specified would be justifiable under the circumstances. 

TERMINATION OF ELECTION. Any election approved by the department shall be automatically void as of the date the employer is determined  
liable by the state which issued the waiver of coverage, with respect to the individuals covered by this election. The department may at any  
time,own its cancelmotion, on  an approvedelection under the provisions (j) 4 Pennsylvaniaof the of Section CompensationUnemployment    
Law. 

Auxiliary aids and services are available upon request to individuals with disabilities. 
Equal Opportunity Employer/Program 
UC-8A REV 09-21 (Page 2)