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Application for Unemployment Insurance, Disability Insurance, and Paid Family Leave Elective
Coverage Under Section 708(a) of the California Unemployment Insurance Code
Complete this application only if you meet the requirements as set FOR DEPARTMENT USE ONLY
forth in the attached Information Concerning Elective Coverage. DIEC
APPROVED: DENIED: ACCOUNT # - -
Note: For assistance in completing this application, contact the Taxpayer
Assistance Center at 1-888-745-3886. Upon completion of the Effective Date Subject
application, return to: Quarter -
Attention: FACD – Central Operations, MIC 94 Send Forms
Employment Development Department DE 2515, DE 3816DI, DE 1378DI DE 3DI Qtr(s)
PO Box 826880 Date Forms Sent: Approved By: Approval Date:
Sacramento, CA 94280-0001 On-lined by: On-lined date:
1. Social Security Number* 2. Employer Account Number 3. Gender 4. Year of Birth
- - - - Male Female
5. First Name Middle Initial Last Name 6. Have you applied for elective coverage before?
Yes No
If yes,
Mo. Yr.
7. Mailing Address: Number and Street or PO Box City ZIP Code

8. Business Name (If Any) Business Phone
( )
9. Business Address: Number and Street or PO Box City ZIP Code

10. Email Address 11. Website

12. Do you have any employees? If yes, and you are not registered with the Employment Development Department (EDD) as an employer, please explain:
Yes No If no, see instructions
13. Type of Organization: Corporation – Do not submit, corporate officers are employees and covered.
General Partnership (includes husband and wife co-owners who are both active in the operation and management of the business)
Individual Limited Partnership – only general partners may apply
Limited Liability Partnership – only general partners may apply Limited Liability Company – Partnership
Limited Liability Company – Sole Proprietorship Managing Member
14. Name(s) and Title of All Partners and Members (continue on another page if necessary)
General Partners/Members Social Security Number* Limited Partners/Members Social Security Number*

15. Nature of Business:
Contracting Manufacturing Repairing
Retail Service Wholesale Other (describe):
16. Your Occupation/Title 17. Describe (in detail) your specific business (such as the type of service, products, etc.):

18. Is a license or permit required in your trade, business or occupation? Yes No Do you possess such a valid and active license? Provide License/Permit Number
If yes, indicate type of license or permit required: Yes No

19. Are you conducting a seasonal type of business? Yes No 20. Do you expect to remain in business for the next eight (8) calendar quarters?
If yes, and you answer no on #23, do not submit. You are not eligible for this coverage. Yes No If no, do not submit. You are not eligible for this coverage.
See information sheet attached. See information sheet attached.
21. How many hours a day, week, month do you perform your services? 22. Do you limit the number of hours you perform services?
Include administrative hours and time spent soliciting customers.
Day Week Month (complete all three) Yes No (If yes, explain in #31)
(Hours) (Hours) (Hours)
*The disclosure of your Social Security number is mandatory under the Federal Tax Reform Act of 1976.

DE 1378A Rev. 40 (1-22) (INTERNET) Page 1 of 5 CU

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23.  Do you perform services in your trade, business, or occupation continuously             If no, explain.
    throughout the year? (Include time spent doing office work, soliciting customers
    and maintaining machinery and equipment.)
    Yes                No
24.  How long have you had employees working for you?
               Year(s)                                  Month(s)                             If less than one year, give date first employee was hired.  ____ / ____/ __________
25.  If you are self-employed and also an employee, do you receive the major part of         If no, explain major source of remuneration.
    your income from your self-employment?        Yes        No
    If yes, what percentage?               %
26. If you were self-employed during the last two years, what was your net profit as If you have never filed a Schedule SE with the IRS, did you have net profit in excess of $4,600 
    shown on your IRS Schedule SE, Line 3?                                           last year?
                                                                                                                                                       Yes      No
     ___________ $ _____________             __________      $ ______________
    Year                 Net Profit               Year       Net Profit              If you have been in business for less than one year, did your average net profit exceed $1,150 
                                                                                     per quarter?
                                                                                                                                                       Yes      No
                                                                                     If you have been in business less than one quarter, do you expect your average net profit to 
                                                                                     exceed $1,150 per quarter during the first year in business?
                                                                                                                                                       Yes      No
Please submit copies of your IRS Schedule SE for the last two years. If only in business one year, enter zero (0) for the other year.
If you answered no to all three questions, do not submit this application until you earn the required minimum net profit in your trade, business, or occupation.
27.  Were you convicted of a misdemeanor and/or felony under the California Unemployment Insurance Code during the last eight (8) calendar quarters?
    (See attached information sheet)        Yes        No
28.  Are you presently unable to perform all your regular and customary services in connection with your trade, business or occupation due to a disability or a family care, bonding or
    military assist need?
    Yes                No    If yes, wait to submit until you are able to perform all duties.
29. During the last three months, have you been off work due to a disability or      If yes, did you file a claim for  When did you resume your usual duties?
    the need to care for a seriously ill family member, to bond with a new child,    benefits?                         (Do not file this application if you are currently disabled.)
    or to participate in a qualifying event as a result of a family member’s military
    deployment to a foreign country?
                                                                                                                                     /   / 
    Yes                No                                                                    Yes            No
30. On what date do you wish elective coverage to commence? Keep in mind that the commencement date of an elective coverage agreement shall not be prior to the first day of the
    calendar quarter in which the application is filed, nor later than the first day of the following calendar quarter.
    First Day of Current Quarter                             Day First Employee Hired                         First Day of Next Quarter

    Use the space below to include any additional information

Note:   To collect UI benefits, you must show that you were in satisfactory immigration status and authorized to work in the 
         United States when earning the wages you used to establish your claim.
                                                                                     Declaration
I, the undersigned, declare that the statements made on this application are true and correct to my best knowledge and belief. I understand that providing false information will result in 
denial or termination of coverage. I hereby elect and make application to have my services considered as employment subject to the California Unemployment Insurance Code (CUIC) 
for Unemployment Insurance, State Disability Insurance, and Paid Family Leave. I hereby authorize the verification of any information provided by me on this application. I understand 
that this election must remain in effect for two complete calendar years unless I no longer meet all of the eligibility requirements of section 704 of the CUIC or I meet the conditions for 
termination of coverage under section 704.1 of the CUIC.
Signature of Applicant                                                                                                                   Date

Residence Address (Number and Street or PO Box, Street, City, and ZIP Code)                                                              Residence Phone

                                                                                                                                         (   )
Application must be signed to be valid.

DE 1378A Rev. 40 (1-22) (INTERNET)                                                   Page 2 of 5                                                                                CU

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Information Concerning Unemployment Insurance, State Disability Insurance, and Paid Family
Leave Elective Coverage Under Section 708(a) of the California Unemployment Insurance Code

Do not send any payment with this application. Contributions are not payable in advance.
You will receive a written notice of the approval or denial of your application.
If your agreement is approved, you will receive instructions on how to file your returns and pay the premiums due. You cannot pay
before you receive approval. Your agreement is subject to the requirements outlined below.

Please retain this page for reference.
Note: Self-employed individuals are only eligible for Disability Insurance (DI) and Paid Family Leave (PFL) coverage under section
708.5 of the California Unemployment Insurance Code (CUIC) (leginfo.legislature.ca.gov/faces/codes.xhtml). To apply for DI/
PFL coverage only, use the Application for Disability Insurance Elective Coverage (DE 1378DI)(PDF)
(edd.ca.gov/pdf_pub_ctr/de1378di.pdf).

Persons Eligible to Elect Coverage
Section 708(a) of the CUIC provides that any individual who is an employer under section 675 of the CUIC, or two or more individuals
who have qualified, may elect coverage. Each individual who applies must provide evidence of a yearly net income (after all taxes
and deductions) of at least $4,600, or an average of $1,150 per quarter if in business for less than one year.
Qualifying employers include sole proprietors, general partners, managing members of Limited Liability Companies (LLC) treated as
sole-proprietors for federal income tax purposes, and members of LLCs treated as partnerships for federal income tax reporting
purposes. It is not required that all active general partners or members be included in the election. An active general partnership also
includes a husband and wife co-ownership in which both spouses are active in the operation and management of the business.
Limited partners and corporate officers are considered to be employees subject to the compulsory provisions of the CUIC, the same
as all other employees, and are not eligible to elect self-coverage.
Note: To elect only DI and PFL coverage under section 708(b), use the DE 1378DI.

Conditions for Denial of Coverage
Section 704 of the CUIC provides that an election under section 708(a) of the CUIC shall not be approved if it is found that any of the
following conditions exist:
(a) The self-employed individual is currently unable to perform his or her regular and customary work due to injury or illness.
(b) The employing unit or self-employed individual is not normally and continuously engaged in a regular trade, business, or
occupation.
(c) The employing unit or self-employed individual intends to discontinue the regular trade, business, or occupation within eight
calendar quarters.
(d) The regular trade, business, or occupation of the employing unit or self-employed individual is seasonal in its operations.
(e) The major portion of the self-employed individual’s remuneration is not derived from his or her trade, business, or occupation.
(f) The self-employed individual is unable to provide a copy of his or her Internal Revenue Service (IRS) Schedule SE for the
preceding year showing a net profit of at least $4,600 or to certify to an average net profit of at least $1,150 per quarter since
becoming self-employed or for the preceding four quarters, whichever period is less.
(g) The employing unit or self-employed individual has failed to make a return or to pay contributions within the time required,
pursuant to the CUIC, and there is an unpaid amount of contributions owing by the employing unit or self-employed individual.
(h) Section 704(h) (1) and (2) of the CUIC: (1) A prior elective coverage agreement entered into pursuant to section 708 or 708.5 of
the CUIC has been terminated by the department under section 704.1 of the CUIC or by means of a written application for
termination as required by this division, and the individual has not completed a waiting period of 18 consecutive months from
the date of termination. (2) The waiting period for reinstatement to the elective coverage program may be waived for any
individual who becomes eligible for coverage after being terminated under paragraph (1), (2), (4), or (5) of subdivision (a) of
section 704.1 of the CUIC, upon receipt by the department of an application for coverage to be effective the first day of the
quarter in which the application is received.
(i) The employing unit or any officer or agent or person having charge of the affairs of the employing unit, or the self-employed
individual has been convicted within the preceding eight consecutive calendar quarters of any violation under Chapter 10
(commencing with section 2101 of the CUIC). For the purposes of this subdivision, a plea or verdict of guilty or a conviction
following a plea of nolo contendere is deemed to be a conviction irrespective of whether an order granting probation or other
order is made suspending the imposition of the sentence or whether sentence is imposed for execution thereof is suspended.

DE 1378A Rev. 40 (1-22) (INTERNET) Page 3 of 5 CU

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(j) For purposes of this section, IRS Schedule SE is defined as IRS Form 1040 Schedule SE, or in the case of statutory
employees under the Internal Revenue Code, it shall be defined as IRS Form 1040 Schedule C, or the California Income Tax
Return, when accompanied by IRS Form W-2.

Cost of Coverage
You will receive notification of the following year’s premium rate, reportable income credits, and premiums payable with your fourth quarter
premium notice. You may estimate the cost of coverage using form Disability Insurance Elective Coverage (DIEC) Rate Notice and
Instructions for Computing Annual Premiums (DE 3DI-I) (PDF) (edd.ca.gov/pdf_pub_ctr/de3dii.pdf), or call the phone number shown on
the front of your application for assistance.
Use the same Unemployment Insurance (UI) rate as the one you use for your employees and, regardless of your actual earnings,
report both total and taxable quarterly wages in the amount determined by the EDD pursuant to the formula provided in the CUIC. Total
wage information is necessary to provide maximum benefits and to serve as a basis for collecting contributions for the coverage.
For reporting the proper amount of wages, see Instructions for Reporting Wages and Contributions for Employers Who Have
Elected Unemployment and State Disability Insurance Coverage Under Section 708(a) of California’s Unemployment Insurance
Code (CUIC) (DE 3F) (PDF) (edd.ca.gov/pdf_pub_ctr/de3f.pdf). This will be mailed to you each quarter with your reporting forms.

Quarterly Reports Required
The Quarterly Premium Notice for Disability Insurance Elective Coverage (DE 3DI) and the Quarterly Contribution Return and
Report of Wages (Continuation) (DE 9C) must be filed each quarter whether or not payments are due. The DE 3DI and DE 9C are
mailed to you each quarter. These reports are due on the first day of the first month of the following calendar quarter, and are
delinquent if not paid on or before the last day of that month. These reports must be filed whether or not payments are due. Failure
to receive a reporting form does not relieve you of the responsibility to make your payments on time. Submitting the DE 3DI with DI
or PFL information is not a claim for benefits.

Reportable Compensation for Disability Insurance
Any adjustment of the reportable income credits and premiums due to DI or PFL must be noted on the DE 3DI. If you have any
questions regarding computing or adjusting the premium base and premiums, please contact the Taxpayer Assistance Center at
1-888-745-3886.
For an explanation of reportable compensation for UI, refer to the DE 3F.

Benefit Eligibility
The EDD determines eligibility for UI, DI, and PFL benefits pursuant to the CUIC and authorized regulations. Generally, a
minimum of seven months must elapse from the commencement date of coverage before a valid claim may be filed based
solely on income credits reportable under your election. Eligibility is dependent on a number of factors including: proof of a
claimant’s eligibility, filing of a timely claim for benefits, and filing and payment of all required reports and amounts due. Weekly DI or
PFL benefits are payable under elective coverage regardless of whether the claimant continues to receive any compensation from
his/her business.
DI provides benefits to individuals who take time off of work due to their own non-work-related disability. Disability is defined as an
illness or injury, either physical or mental, which prevents you from performing your regular and customary work. Disability also
includes elective surgery, pregnancy, childbirth, or other related medical conditions. DI may cover both work related and non-work-
related injuries and illnesses. For DI benefits and eligibility see the pamphlet Disability Insurance Provisions (DE 2515)(PDF)
(edd.ca.gov/pdf_pub_ctr/de2515.pdf) or contact your DI field office at 1-800-480-3287.
PFL provides benefits to individuals who need to take time off work to:
• Care for a seriously ill family member (child, parent, parent-in-law, grandparent, grandchild, sibling, spouse, or registered
domestic partner).
• Bond with a new child entering the family by birth, adoption, or foster care placement.
• Participate in a qualifying event because of a family member’s (spouse, registered domestic partner, parent, or child) military
deployment to a foreign country.
c Deployment is defined as covered active duty, a call or notice of impending covered active duty, or a rest and
recuperation leave from covered active duty.
c A qualifying event is any military event or an essential need resulting from the family member’s deployment to a
foreign country.
For information on PFL benefits and eligibility, refer to brochure Paid Family Leave (DE 2511)(PDF)
(edd.ca.gov/pdf_pub_ctr/de2511.pdf) or call PFL at 1-877-238-4373.

DE 1378A Rev. 40 (1-22) (INTERNET) Page 4 of 5 CU

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Non-US Citizens
To collect UI benefits, you must show that you were in satisfactory immigration status and authorized to work in the United States
when earning the wages you used to establish your claim. You must also give proof that you are currently in satisfactory
immigration status, and are authorized to work each week that you claim benefits. The EDD verifies immigration status and work
authorization through Department of Homeland Security.

Cancellation/Termination of Elective Coverage
A participant may cancel his or her elective coverage agreement as of January 1 of any calendar year, only if the agreement has
been in effect for two complete calendar years, by sending a letter to the EDD at the address above requesting termination on or
before January 31 of that year.
The EDD may terminate the UI coverage if the employer no longer qualifies as an employer for one complete calendar year.
The EDD may terminate your entire elective coverage agreement if it is found that any of the “Conditions for Denial of Coverage” exist
or you meet one of the following conditions for termination of coverage by the EDD found in section 704.1 of the CUIC:
• Section 704.1(a)(5): The self-employed individual reports a net profit of less than $4,600 on his or her IRS Schedule SE for a third
consecutive year.
• Section 704.1(a)(7): The employing unit or self-employed individual, or a representative thereof, is found to have filed a false
statement in order to be considered eligible for elective coverage.
You will be given written notification of the EDD’s termination of your elective coverage agreement and will have 30 days to file a
Petition for Review of the termination of elective coverage. The termination shall not affect the liability of the self-employed
individual for any premiums due, owing, or unpaid to the EDD. Termination by the EDD may affect your ability to draw benefits.
The EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Requests for
services, aids, and/or alternate formats need to be made by calling 1-888-745-3886 (voice) or TTY 1-800-547-9565.

DE 1378A Rev. 40 (1-22) (INTERNET) Page 5 of 5 CU

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