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

Fax Number: 217-557-1948         33 South State Street, Chicago, IL 60603

Employer’s Name ______________________________       Illinois Account Number ______________ 

FEIN ________________________ 

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

Telephone Number ______________________ 

The employer requests that the Illinois Department of Employment Security enter into a reciprocal 
coverage arrangement with each of the following other States where individuals named under Item 
2, on the RC-1 form may do some work for the employer and under whose unemployment insurance 
laws they may be covered:

                         (j) __________________  (k) __________________ (l) ________________
                         (m)__________________ (n)___________________(o)________________
                         (p)___________________(q)___________________(r)________________
                         (s)___________________ (t)___________________ (u)_____ __________
                         (v)__________________  (w)___________________(x)________________
                         (y) __________________ (z)____________________

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.  

Name                     Social Security Number    State of  Employee Base                        Reason 
                                            Residence       of Operation        

RC-1A (Rev.  /9 2017)