FOR DEPARTMENT USE ONLY 
                                                                         ACCOUNT NUMBER              STATISTICAL CODE 

                                                                         EFFECTIVE DATE              DATE EMPLOYER NOTIFIED 
Analysis Resolution and Correspondence Organization 
PO Box 2068                                                              APPROVED BY                           DATE APPROVED 
Rancho Cordova, CA 95741-2068         888-745-3886 

APPLICATION FOR ELECTIVE COVERAGE OF                                     SEND                                  NUMBER OF EMPLOYEES 
DISABILITY INSURANCE (Excluded Family  Employment) 
Reference: Section 702.5 of the California  Unemployment Insurance Code  
                        PLEASE PRINT OR TYPE 
                                                                   IMPORTANT 
This form is not an application for an account number under the compulsory provisions of the California Unemployment Insurance Code (CUIC). Do not 
complete this form unless both the owner of the entity described herein and its family employees, excluded under Section 631 of the CUIC, wish to have 
the employees’ services voluntarily covered for State Disability  Insurance* under the provisions of Section 702.5 of the CUIC.  
1.  Employer Name                                                                                    Social Security Number  

2. Business Name 

3.  Business Address             Number and Street                             City and State        ZIP Code  

4.  Mailing Address              Number and Street                             City and State        ZIP Code  

5.  Your Employer Payroll Tax Account Number(s), if any 

6.  Nature of Business (Check One)
          Retail Trade                     Service                Manufacturing     Agricultural 
          Wholesale Trade                  Repairing              Contracting       Other 
   Describe product or service:                                          Manufacturers: List principal products in order of importance:  

7.  If your business is seasonal, in what months do you operate? 

8.  Do you expect to remain in business for the next eight (8) calendar quarters? 

9.  What types of services are performed by excluded family employees? 

10.  Do you report (or are you required to report) to Social Security for excluded family  employees?
          Yes 
         No (Please explain)  

11.  How many  employees will be covered by this agreement? 

12.  What is the number of locations at which your business is conducted in California? 

   List locations covered by this application.  

13.  Deductions should not be made from your employees’ wages for the purpose of paying contributions until your application has 
   been approved. If deductions have already been made, indicate beginning date. 
   Deducted From (Date)          Amount                          Were such deductions made on all employees covered by this application?  
                                 $      
14.  On what date do  you desire elective coverage to begin?
          First Day of Current Quarter               First Day of Next Quarter 

*Includes Paid Family Leave (PFL). 
                                                         CONTINUED ON REVERSE  
DE 1378J Rev. 10 (8-16) (INTERNET)                                 Page 1 of 2                                                           CU 

 CU 
 
  No   No   No   No  
 wages 
             
  Yes      Yes      Yes      Yes    
Will you pay to this person?  If so, how often? (Weekly, monthly, etc.) How often?       How often?       How often?       How often?       ZIP Code 

Month(s) Month(s) Month(s) Month(s)
            
How long has the person been working in your business?  
 
  No   No   No   No 
            
  Yes      Yes      Yes      Yes    
 
Has this person filed a claim for benefits within the last three months? 

  No   No   No   No Residence Address Number and Street City and State   
        
  Yes      Yes      Yes      Yes    Page 2 of 2 
 
 wages reportable under your election. 
 
Is this person currently performing normal and customary services in connection with the operation of your business? (If no, explain below.) 
      Reform Act of 1976. The number will be used for identification purposes and will be available only to authorized 

 Insurance only. The elective agreement is to be in effect for at least two complete calendar years or until termination of employment Date Residence Phone  and other government agencies as permitted in Sections 322 and 1095 of the CUIC. 
      
Relationship Relationship Relationship  
Social Security Number       Social Security Number       Social Security Number       Social Security Number       

 800-547-9565. 
Age Relationship  
  
 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 
 
(INTERNET)  
 
 Number Disclosure: 
    
  If your application is approved, the elective coverage agreement will be subject to all of the requirements and conditions of Sections 631, 702.5, 704, and 707 of the CUIC. Eligibility for State Disability Insurance* benefits under the CUIC does not begin with the commencement date of coverage. Generally, a minimum of seven (7) months must elapse from the commencement date of coverage before a valid claim may be filed based solely on  The employees who are covered by election under Section 702.5 of the CUIC are also subject to the California Personal Income Tax (PIT) withholding law. Agricultural employees are not subject to the California PIT withholding law unless both the employer and employee agree to have the state PIT withheld. 

 List the name(s), age(s), relationship, and Social Security number(s) of those electing the coverage. The signature of each employee electing the coverage is required for this election. (If more space is needed, please attach a continuation sheet with the needed information and signatures.) Name Age       Signature Name       Signature Name Age       Signature Name Age       Signature Explanation       NOTE: CERTIFICATION:  I, the undersigned, certify that the statements made in this application are true and correct to my best knowledge and belief. I hereby elect and make application to have the excluded family services considered as employment subject to the CUIC for State Disability in my business. The elective agreement may be terminated by filing a request for termination by January 31 of any year following two complete years of elective coverage.  Employer Signature   Business Phone       NOTE: Wages and Contributions, Section 702.5: Contributions to be paid for “Family Employment” elective coverage are to be based upon actual wages paid to covered family members for services performed up to a maximum wage limitation for the year for each family member.  There is no provision in this section to permit the contributions to be based on other than actual wages paid.  The amount of any disability benefits paid will also be determined on the basis of wages paid. Social Security The disclosure of your Social Security number is mandatory under the Federal Tax personnel within the Employment Development Department (EDD) The EDD is an equal opportunity made by calling 888-745-3886 (voice) or TTY *Includes PFL DE 1378J Rev. 10 (8-16)