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 and forward to: Department of Labor & Industry, Office of UC Tax Services, Status 
Determinations Unit, 651 Boas Street, Room 800, Harrisburg, PA 17121-0750. 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: 

  Individual           Partnership                     Association 
  Domestic Corporation (Pennsylvania)                                                            Date of Incorporation:  
  Foreign Corporation             State of Incorporation:                                                                 Date of PA Certificate of Authority: 
  Limited Liability Company      State Where Chartered: 
  Other (identify)   
                      EMPLOYEE’S NAME                SOCIAL SECURITY NUMBER                                                                 STATE OF  STATE FROM WHICH STATE 
                                                                                                                                            RESIDENCE EMPLOYEE’S WORK  IN WHICH SERVICE 
                                                                                                                                                      IS CONTROLLED    IS PERFORMED 

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 
                      
   APPROVED                      DISAPPROVED                                                                                                 
EFFECTIVE DATE                                                                                               By 
                                                                                                                                            Assistant Director, Central Operations Division 
                                                                                                                                         
UC-8A REV 05-20 (Page 1) 

Article I, Section 4 of the Pennsylvania Unemployment Compensation Law defines “State” as any one of the 
fifty states of the United States, Puerto Rico, Virgin Islands, and the District of Columbia. It also provides 
that an  employer subject to the Pennsylvania Unemployment Compensation Law may elect to include within 
the term “employment”, subject to the Act, services  performed by his or its employees with 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  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, on its own motion, cancel an election 
approved under the provisions of Section 4 (j) of the Pennsylvania Unemployment Compensation Law. 

                         Department of Labor & Industry | Office of UC Tax Services 
                         651 Boas Street | Harrisburg, PA 17121-0750 | www.uc.pa.gov 
                         Auxiliary aids and services are available upon request to individuals with disabilities.
                                   Equal Opportunity Employer/Program
UC-8A REV 05-20 (Page 2)