Employer Election To Cover Multi-State Workers 
                       Under the Illinois Unemployment Insurance Act 

Fax: 217-557-1948      33 SOUTH STATE STREET CHICAGO, ILLINOIS  60603

Employer’s Name                                Illinois Account Number 

FEIN _____ ___________________

Address ______________________________________________________________________________ 
              (Street)                                      (City)                          (State)                  (Zip Code) 

Telephone Number ______________________ 

The above employer requests that the Illinois Department of Employment Security cover under the Illinois 
Unemployment Insurance Act certain individuals (named below and on any attached forms) customarily 
employed by the employer and who works in more than one state. 

1     The employer requests to enter into a reciprocal coverage arrangement  with the Illinois Department 
      of Employment Security to that effect, with each of the following other States in which the 
      individual(s) named under Item 2 may do some work for the employer, and under whose 
      unemployment insurance laws they might otherwise be covered):

      (a)               (b)            (c)                       (d)                   (e) _______________
      (f)                (g)           (h)                        (i) _______________  

      The Employer must submit two signed copies of this form plus two additional copies for EACH state listed 
      above.   These forms should be sent to the Illinois Department of Employment Security at the address  provided 
      above. 

      (If more space is required, use and attach Form RC-1A) 

2.    Basis for Election in Illinois:
      (A).  If any part of the individual’s services are performed in Illinois, enter  “work” under the reason below.
      (B).  If the individual has his residence in Illinois, enter “residence” under the reason below.
      (C).  If the employer maintains a place of business in Illinois and the employee does not reside in or perform
      services in another jurisdiction where the employer is liable, enter “place” of  business under the reason below.

      List of Workers covered by this election:

Name                      Social Security Number    State of Residence   Employee Base of Operation     Reason       
_______________  _____________________  ________________   ________________________  _____________ 
_______________  _____________________  ________________   ________________________  _____________ 
_______________  _____________________  ________________   ________________________  _____________ 
     (If more space is required, use and attach form RC-1A) 

RC-1 
(Rev. 9/17)                             (See Next Page) 

                                 Election   (Continued) 

3. Nature of employer’s business: ________________________________________________________________

4. The employer has a place of business in the following States listed: __________________________________
_____________________________________________________________________________________________
5. Nature of work to be performed by the individuals listed under Item 2: ______________________________
   _____________________________________________________________________________________________
6. Employer’s reason for requesting coverage in Illinois: ____________________________________________
_____________________________________________________________________________________________
7. The employer requests that this election become effective as of the beginning of a calendar quarter,
namely as of  _______________________________________________________________________________
  _____________________________________________________________________________________________ 
8. This election, if approved, shall remain operative, as to the individuals listed herewith, until terminated in
accordance with the currently applicable provisions of the Unemployment Insurance Act.

9. The employer hereby agrees to give each individual covered by this section a notice promptly after its
approval on a Form RC-2 to be supplied by the Illinois Department of Employment Security and to file
copies with the Illinois Department of Employment Security. 

10. The employer agrees to comply with any requirements applicable to this election under the Illinois
Unemployment Insurance Act.

11. To prevent this election from denying unemployment insurance coverage to workers not listed,
theemployer agrees with each State approving this election that it may count the workers covered by this
election, and their wages, as if this election did not apply, for the purpose of determining  whether the
employer is covered by the law of such State and whether any other workers employed by him are
covered.

Certification: I hereby certify that the information contained in this report and any sheets attached hereto is 
true and correct.   This report must be signed by owner, partner, officer or authorized agent within the 
employing enterprise.   If signed by any other person, a power of attorney must be attached. 

Employer Name _____________________________________________________________________________ 

Signed By ____________________________________________      Date _______________________________ 
Title        

                                 APPROVAL
                                 by the 
             Director of the Illinois Department of Employment Security 
The foregoing election is hereby approved, in accordance with the applicable provisions of the 
Unemployment Insurance Act, as submitted by the electing employer. 

Date __________________________    _____________________________________________ 
                                                            Director of Employment Security 

RC-1

Election   (Continued) 

      Approval by the Interested Jurisdiction of ____________________________________________________  

          The foregoing election is similarly approved. 

                                             Name of Agency _______________________________________
                                             By ___________________________________________________
                                             Title _________________________________________________  
                                             Telephone Number _____________________________________  

Note: The employer must submit two signed copies of this form plus two additional copies for EACH state listed above.  
These forms should be sent to the Illinois Department of Employment Security at the address provided above. 
We will forward 2 copies to each “interested jurisdiction” for action and, when advised of such action, will 
notify the employer accordingly. 

RC-1

Fax: 217-557-1948  33 SOUTH STATE STREET,Chicago, Illinois 60603          

Employer’s Name  

Illinois Account Number                              FEIN 
Employer’s Address 
                                 (Street and Number)  (City and State)     (Zip Code) 

Telephone Number  

Employee’s Name                                  Social Security Number  

Residence Address 
                         (Street and Number)           (City and State)                      (Zip Code) 

Inasmuch as I customarily perform services for the above employer in more than one state, namely: 

_____________________________      __________________________   __________________________ 

_____________________________      __________________________   __________________________ 

_____________________________      __________________________   __________________________ 

 I, the undersigned, concur in my employer’s request that my services for the purposes of  
 Unemployment Insurance be deemed to be performed entirely within the State of Illinois effective 
 as of             , and hereby consent to such determination.  This coverage is to remain in effect 
 until such time as the conditions of my employment with respect to where my services are performed 
 change to the extent that I no longer customarily perform services in more than one state, or the  
 agreement is otherwise terminated. 

    I also acknowledge and understand that this consent may effect any benefits I may receive upon filing  
for Unemployment Benefits at any future date.  

 Date                                Signed ________________________________________
                                                     (Employee)