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Application for Disability Insurance Elective Coverage (DIEC)
For Department Use Only
Complete this application only if you meet the requirements as set
forth in the attached Information Concerning Disability Insurance DIEC DIEC
Elective Coverage. Approved: 708(b) 708.5 Account #
Note: For assistance in completing this application, contact Effective Date: Subject
Quarter
the Taxpayer Assistance Center at 1-888-745-3886.
Upon completion of this application, return to: Send Forms
DE 2515, DE 3816DI DE 3DI Qtr(s)
Attention: FACD - Central Operations, MIC 94 Date Forms Sent: Approved By: Approval Date:
Employment Development Department
PO Box 826880 Rev/Reg By: Rev/Reg Date:
Sacramento, CA 94280-0001
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
13. Type of Organization: Corporation - Do not submit, corporate officers are employees and covered under the State Disability Insurance Program.
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 partner 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/Managing Members Social Security Number*

15. Nature of Business:
Contracting Manufacturing Repairing
Retail Services 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 Provide License/Permit Number
If yes, indicate type of license or permit required: license?
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, do not submit. You are not eligible for this coverage. See information sheet attached.
Yes No If no, do not submit. You are not eligible for this coverage.
See information sheet attached.
21. Do you perform services in your trade, business, or occupation continuously throughout the year? If no, explain.
(Include time spent doing office work, soliciting customers, and maintaining machinery and
equipment.)
Yes No

*The disclosure of your Social Security number is mandatory under the Federal Tax Reform Act of 1976.

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22. How long have you performed services as a self-employed individual, partner, or member? Year(s) Month(s)
If less than 1 year, give date business started
23. Do you perform your services under a written contract or agreement?
Yes (Please attach copy) or (Explain oral agreement in #32)
No
24. Is the major part of your service(s) performed for any specific firm or individual? If yes, identify the business name and address.
Yes No
25. Have you previously worked as an employee for a firm for which you are now performing services? If yes, explain services performed as an employee.
Yes No
26. If you are self-employed, and also an employee, do you receive the major part of your income from your self-employment?
Yes If yes, what percentage?
No If no, explain major source of remuneration.
27. If you were self-employed during the last two years, what was your net profit as shown on your IRS If you have never filed a Schedule SE with the IRS, did you have net profit in excess of
Schedule SE, line 3? $4,600 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 just started a business, do you expect to earn a net profit of at least $1,150 per quarter
through the end of the year?
Yes No
Please submit copies of your IRS Schedule SE for the last two years. If only in business one year, enter zero 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.
28. Were you convicted of a misdemeanor and/or a felony under the California Unemployment Insurance Code (CUIC) during the last eight (8) calendar quarters? (See attached information sheet) Yes No
29. 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?
(Do not file application if you are currently disabled.) Yes No
If yes, did you file a claim for benefits? Yes No
30. During the last three months, have you been off work due to a disability If yes, did you file a claim for benefits? When did you resume your usual duties?
or the need to care for a seriously ill family member, to bond with a new
child, or to participate in a qualifying event as a result of a family Yes No
member’s military deployment to a foreign country? Yes No
31. 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 First Day of Next Quarter
32. Additional Information (Use this space to more fully discuss the above questions).

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 CUIC for State Disability
Insurance only. 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, City, and ZIP Code) Residence Phone

Application must be signed to be valid.

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Information Concerning Disability Insurance Elective Coverage* Under Sections 708(b) and 708.5 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 elective coverage agreement is approved, instructions will be sent to you for filing your returns and paying the premiums
due. Your agreement is subject to the requirements and conditions outlined below.

Please retain this page for reference.

Persons Eligible to Elect Coverage
• Section 708(b) of the California Unemployment Insurance Code (CUIC) (leginfo.legislature.ca.gov/faces/codes.xhtml) pro-
vides that an individual who is an employer under section 675 of the CUIC, or two or more individuals who have so qualified,
may elect coverage. Each individual who applies must provide evidence of an annual net profit of at least $4,600 or average
$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.

• Section 708.5 of the CUIC provides that self-employed individuals who receive the major portion of their remuneration from
the trade, business, or occupation in which they are self-employed, may elect coverage. Annual net profit must be at least
$4,600 or average $1,150 per quarter if in business for less than one year.
Conditions for Denial of Coverage
Section 704 of the CUIC provides that an election under section 708(b) or section 708.5 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 Services (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 of 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

*Includes Paid Family Leave

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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.
(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 (law.cornell.edu/uscode/text/26), it shall be defined as IRS Form 1040 (irs.gov)
Schedule C, or the California Resident Income Tax Return, DE 540, when accompanied by IRS Form W-2 (irs.gov).
Elections filed under section 708.5 of the CUIC are subject to verification by the Employment Development Department (EDD)
that the individual is in fact self-employed rather than an employee of another individual or firm. If an individual filing an
application for coverage under section 708.5 of the CUIC as a self-employed individual has any knowledge of a prior ruling
issued by the EDD concerning his or her status, reference to such ruling should be made on the application form and, if
possible, a copy of the ruling attached.

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.

Quarterly Report Required
The Quarterly Premium Notice for Disability Insurance Elective Coverage (DE 3DI) must be filed each quarter whether or not
premiums are due. This notice is normally mailed by the last day of the calendar quarter. The DE 3DI and premiums are due on
the first day of the following calendar quarter and become delinquent if not paid on or before the last day of that month. Failure
to receive a DE 3DI does not relieve you of the responsibility to pay your premiums on time. Submitting the DE 3DI with disability
information is not a claim for benefits. Contact your local Disability Insurance benefit office for claim information.

Reportable Compensation
Any adjustment of the reportable income credits and premiums due to Disability Insurance (DI) or Paid Family Leave (PFL) must
be noted on the DE 3DI. If you have any questions regarding computing or adjusting the reportable income credits and premiums,
please contact the Taxpayer Assistance Center at 1-888-745-3886.

Benefit Eligibility
The EDD determines eligibility for DI and PFL benefits pursuant to the CUIC and authorized regulations. Generally, a
minimum of several 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 or 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 do-
mestic 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.
○ 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.
○ 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

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Cancellation/Termination of Elective Coverage
A participant may cancel his or her elective coverage agreement as of January 1 of any calendar year, and 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 your 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 Service 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 by the director 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 DI 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 1378DI Rev. 45 (1-22) (INTERNET) Page 5 of 5

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