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                                                                                              Do Not Write in This Space 
                                                                                Account Number  
                                                                                Statistical Code  
APPLICATION FOR UNEMPLOYMENT AND DISABILITY                                     Subject Quarter  
INSURANCE ELECTIVE COVERAGE FOR EMPLOYEES                                       Send Forms                          Sent Forms  
EXCLUDED UNDER THE CALIFORNIA UNEMPLOYMENT                                      Classified By                       Date   
INSURANCE CODE (CUIC) 
Return this form to:  
Employment Development Department 
Taxpayer Assistance Center 
Attention: Specialized Coverage Desk 
PO Box 2068  
Rancho Cordova, CA 95741-2068  
888-745-3886  
 
This form is not an application for an account number. Submit a Commercial Employer Account Registration and Update Form, DE 1, to  
obtain an account number. If you are a nonprofit organization, please refer to question 14.  
 
Complete this form only if all of the following exists: 
   Your employees are engaged in employment excluded under the CUIC. 
   A majority of your employees who are engaged in excluded employment want to be covered by the provisions of the CUIC and 
    you agree to such coverage. All employees in any establishment or location must be covered by the election. 
   You and your employees want this coverage to be effective for at least two complete calendar years after the effective date of 
    this agreement. 
 
  1. Business Name:                                                                                                                      
                                                                                                                    (Phone)  
    
  2. Business Address:                                                                                                                   
 (Street)                                                                (City)                                     (State) (ZIP Code) 
 
  3. Mailing Address:                                                                                                                    
 (Street)                                                                (City)                                     (State) (ZIP Code) 
 
  4. Type of Organization: Individual        Partnership:  General             Limited   
                         Corporation:  Domestic                Foreign         Other                                                     
    Limited Liability Company (LLC) treated for federal income tax reporting purposes as:  
 Disregarded Entity        Partnership        Corporation                
 
  5. Indicate Owner(s), Corporation Officer(s), Partner(s), Member(s), etc. (Use additional sheets if necessary.) 
 
             FIRST and LAST NAME                                        TITLE                         RESIDENCE ADDRESS 

  6. Check the box for any type of service you want to include under elective coverage: 
 
       Domestic services in a private home where such individual receives less than $1,000 cash remuneration in a calendar quarter 
        (Section 629 of the CUIC). (An individual who receives at least $750 in cash remuneration is mandatorily covered for disability 
        insurance under Section 2606.5 of the CUIC). 
     
       Services as a transcriber of depositions, court proceedings, and hearings performed away from the office of the person, firm, or 
        association obligated to produce a transcript of these proceedings (Section 630 of the CUIC). 
     
    Services described in Section 634.5 of the CUIC: 
          In the employ of a church, convention or association of churches, or an organization operated primarily for religious 
             purposes and is operated, supervised, controlled, or principally supported by a church or convention of churches. 
          By a duly ordained, commissioned, or licensed minister or member of religious order. 

DE 1378 Rev. 34 (8-16) (INTERNET)                        Page 1 of 5                                                                    CU

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Persons receiving rehabilitation or compensative work in a program of either:
(A) Rehabilitation for persons whose earning capacity is impaired by age, physical or mental deficiency or injury.
(B) Providing compensative work for persons who because of their impaired physical or mental capacity cannot be
absorbed in the competitive labor market.
Services performed by an individual receiving work relief or work training in a program financed by any federal agency,
agency of a state of political subdivision thereof, or Indian tribe.
Services by a ward or an inmate of a custodial or penal institution.
Services by individuals under 18 years of age delivering or distributing newspapers or shopping news to ultimate
consumers.
Services by an individual selling newspapers and magazines at a fixed price to ultimate consumers if the compensation is
based on retention of the excess of sales price over cost from supplier.
Persons participating in a national service program carried out using assistance provided under Section 12571 of Title 42 of
the United States Code.
Services for any unemployment system established by a law of the United States (Section 635 of the CUIC).
Domestic services in a local college club or local chapter of a college fraternity or sorority if the remuneration paid is less than
$1,000 cash remuneration in a calendar quarter (Section 639 of the CUIC).
Casual labor not in the course of the employing unit's trade or business (Section 640 of the CUIC).
Services for an organization exempt from income tax if remuneration for such service is less than $50 in any calendar
quarter (Section 641 of the CUIC).
Services performed in the employ of a school, college, or university if such service is performed (Section 642 of the CUIC).
(A) By a student enrolled and regularly attending classes at such school, college, or university.
(B) By a spouse of such student in a program to provide financial assistance to such student. (To be excluded, the spouse
must have been advised that employment would not be covered for unemployment compensation purposes at
commencement of services.)
Services performed as a student nurse, who is enrolled and regularly attending classes in a nurses’ training school, in the employ
of a hospital or nurses’ training school (Section 645 of the CUIC).
Services performed as an intern, who has completed a four years’ course in medical school, in the employ of a hospital
(Section 645 of the CUIC).
Services by a student under the age of 22 in a program combining academic instruction and work experience (Section 646 of the
CUIC).
Services performed for a hospital by a patient of such hospital (Section 647 of the CUIC).
Services on other than an American vessel or aircraft and the service therewith is performed outside the United States
(Section 648 of the CUIC).
Services performed as a real estate, mineral, oil and gas, or cemetery broker or as a real estate, cemetery or direct sales
salesperson, or a yacht broker or salesman, by an individual meeting the following conditions (Section 650 of the CUIC):
(A) The salesperson is licensed under specific provisions of the Business and Professions Code or the Harbors and Navigation
Code or is engaged in the business of primarily in-person demonstration and sales of consumer products (including
services or other intangibles) in the home or sales to any buyer for resale in the home or otherwise than from a retail or
wholesale establishment.
(B) Substantially all of the remuneration for the services is directly related to sales rather than to the number of hours worked.
(C) The services are performed under a written contract expressly providing that the individual will not be treated as an
employee for state tax purposes.
7. Is your business seasonal? Yes No. If "Yes," during what months do you operate?

8. Do you expect to remain in business for the next eight calendar quarters? Yes No

DE 1378 Rev. 34 (8-16) (INTERNET) Page 2 of 5 CU

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9. Indicate the number of different locations at which your activities are conducted in California.

List the addresses of the locations covered by this application.

10. (a) Do you have any employees in California that you do not want included in this coverage? Yes No

If "Yes," what work do they do?

(b) Do these employees perform services at the same establishment or location as those in Item 9? Yes No

If "No," identify the establishment or location at which the services are performed.

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

Disregard Items 12 and 13 if deductions from your employees' wages are already required for State Disability Insurance (SDI)
purposes.

12. SDI 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, list the beginning date and the
amount $ .

13. Were such SDI deductions made on all employees covered by this application? Yes No

14. Is this a nonprofit organization? Yes No
If “Yes,” is it exempt under Section 501(c)(3) of the Internal Revenue Code? Yes No
If “Yes,” submit the Selection of Financing Method by a Nonprofit Organization Described in Section 501(c)(3) of the Internal
Revenue Code, DE 1SNP, form.

15. On what date do you wish elective coverage to commence? First day of current quarter First day of next quarter

The undersigned hereby elects and makes application, under the CUIC, to become an employer subject to the CUIC with respect to all
employment as set forth in this elective coverage agreement. It is understood that upon approval of this election by the Director the
undersigned will be subject to the CUIC as of the date specified in the approval and will continue to be subject for at least two
complete calendar years after the effective date of this agreement and thereafter until this elective coverage is terminated as provided by
the CUIC.

I declare that this application has been examined by me and, to the best of my knowledge and belief, is true and correct and made in
good faith under the provisions of the CUIC, and that I have posted the Notice to Employees Elective Coverage Application for
Unemployment Insurance – State Disability Insurance, DE 1375, in a prominent place on my premises.

This declaration must be signed by one or Signed Date
more persons shown under Item 5. If the
application is a partnership all partners must Print Name
sign the application. If there are more than
three partners, attach a separate sheet Signed Date
bearing the signatures and addresses of
such additional partners. Print Name
(If necessary, attach a separate sheet with
the additional signatures.)

DE 1378 Rev. 34 (8-16) (INTERNET) Page 3 of 5 CU

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INFORMATION CONCERNING EXCLUDED SERVICES AND ELECTIVE COVERAGE
UNDER SECTIONS 702 AND 702.1 OF THE CALIFORNIA UNEMPLOYMENT INSURANCE CODE (CUIC)

SECTION 702

The effect of elective coverage under Section 702 of the CUIC is to extend Unemployment Insurance (UI) and State Disability Insurance
(SDI)* coverage to all employees at a distinct establishment or separate place of business whose services do not constitute employment.

Elective coverage under Section 702 of the CUIC does not apply to those specific family members whose services are excluded under
Section 631 of the CUIC. Elective coverage for these services may be covered for SDI purposes only under Section 702.5 of the CUIC. The
election can be made through the Application for Elective Coverage of State Disability Insurance, DE 1378J.

Employers electing coverage under Section 702 of the CUIC are required to contribute to the UI and Employment Training Tax (ETT) funds
in the same manner as employers covered on a mandatory basis. They are also required to deduct contributions from wages paid
employees as specified in Sections 984 to 988 of the CUIC.

Coverage cannot become effective until approved in writing by the Director. At that time, the employer should begin withholding SDI
contributions from wages paid to its employees.

Example:

Mr. Brown operates a real estate sales business in Los Angeles. All of the salesmen are licensed real estate salesmen meeting all the
requirements to be excluded under Section 650. He also operates a branch office in San Diego and the services of the salesmen there are
also excluded under Section 650 of the CUIC. The salesmen in San Diego want to be covered and those in Los Angeles do not. This can be
accomplished by filing an application for elective coverage under Section 702 of the CUIC and specifying on the application it is intended
to cover only the salesmen at the San Diego office and that coverage is not wanted for the Los Angeles office.

SECTION 702.1

The effect of elective coverage under Section 702.1 of the CUIC is to extend UI and DI coverage to services in the employ of nonprofit
corporations, community chests, funds, or foundations of the type described in Section 608, where some or all of these services are exempt
under Sections 629, 630, 634.5, 635, and 639 to 648 of the CUIC.

Coverage cannot become effective until approved in writing by the Director. At that time, the employer shall begin withholdings SDI
contributions from wages paid its employees.

Any services excluded under Section 634.5 of the CUIC may be excluded from the elective coverage, except services mandatorily included
in "employment" for SDI purposes under Section 2606 of the CUIC (particularly nonprofit hospitals).

Employers electing coverage under Section 702.1 of the CUIC may contribute to the UI and ETT Funds in the same manner as employers
covered on a mandatory basis or they have the option of electing the reimbursable method of financing coverage permitted under
Section 803 of the CUIC. The election for financing method is done by submitting the Selection of Financing Method by a Nonprofit
Organization Described in Section 501(c)(3)of the Internal Revenue Code, DE 1SNP, form.

Elective coverage under Section 702.1 of the CUIC may be terminated by the Department regardless of the length of time it has been in
effect, if the employer elects the reimbursable method of financing for UI under Section 803 of the CUIC and is delinquent in reimbursing
the Department.

Examples:

1. A children's museum is a nonprofit corporation formed to encourage children’s interest in wildlife and nature. The services of most of
its staff are in "employment" under Section 608 of the CUIC. It does, however, have some "work-training" employees whose services
are otherwise excluded under Section 634.5(e) of the CUIC. An election under Section 702.1 of the CUIC would enable the nonprofit
corporation or museum to provide UI-DI coverage to these employees also. The method of financing previously selected with respect
to the employees covered on a mandatory basis under Section 608 of the CUIC would also be applicable to the employees under
elective coverage.

2. A church employs a pastor, an assistant pastor, a handyman-gardener who performs services in and around the church, and a
housekeeper who cooks and keeps house for the pastor and his assistant at the residence provided by the church and located across
the street. The services of all these individuals are excluded under Section 634.5(a)(1) of the CUIC. The church may elect to cover all
of their employees; all except for the pastors; all employees at the church location; all employees at the church except for the pastors;
or all employees at the residence location.

3. A nonprofit hospital, specified in Section 2606 of the CUIC, employs student nurses and interns in addition to its regular staff. The
services of the student nurses and interns are excluded from UI coverage in accordance with Section 645 of the CUIC. Their services
are, however, covered for DI purposes. The hospital may, under Section 702.1 of the CUIC, elect to cover them for UI purposes also.

* Includes Paid Family Leave (PFL).

DE 1378 Rev. 34 (8-16) (INTERNET) Page 4 of 5 CU

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DEFINITION OF A RELIGIOUS ORGANIZATION

Section 634.5(a) of the CUIC excludes services performed for a nonprofit organization (which is described in Section 501[c][3] of the
Internal Revenue Code) from UI and DI if the services are performed in the employ of:

(1) A church or convention or association of churches.

(2) An organization which is operated primarily for religious purposes and which is operated, supervised, controlled, or principally
supported by a church or convention or association of churches.

Accordingly, religious oriented schools that operate within the corporate entity of the church are excluded from UI and DI under
Section 634.5(a)(1) of the CUIC.

Separately incorporated, religious oriented schools, which are nonprofit organizations as described in Section 501(c)(3) of the
Internal Revenue Code, must meet both of the tests contained in Section 634.5(a)(2) of the CUIC. To be considered exempt, the
organization must:

(1) Be operated primarily for religious purposes, and

(2) Be operated, supervised, controlled, or principally supported by a church or association of churches.

Separately incorporated, religious oriented schools are subject to the provisions of the CUIC if they are not operated as stated in
Section 634.5(a)(2) of the CUIC.

TERMINATION OF ELECTIVE COVERAGE

This agreement may be terminated by filing a request for termination during January of any year following two complete calendar years of
coverage after the effective date of this agreement.

The EDD, under Section 704.1 of the CUIC, may terminate elective coverage if it finds that any of the following conditions exist:

1. The employing unit or self-employed individual is not normally or continuously engaged in a regular trade, business, or occupation.

2. The employing unit or self-employed individual has discontinued the regular trade, business, or occupation.

3. The regular trade, business, or occupation of the employing unit or self-employed individual is seasonal in its operations.

4. The employing unit or self-employed individual has failed to make a return or report, or to pay contributions within the time required
and there is an unpaid amount of contributions owing by the employing unit or self-employed individual.

5. 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.

6. The employing unit, any officer, agent of, person having charge of the affairs of the employing unit, or the self-employed individual is
convicted on any violation pursuant to Chapter 10 (commencing with Section 2101 of the CUIC). For the purposes of this paragraph, 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 but
execution thereof is suspended.

PIT WITHHOLDING AND PIT WAGES

Please see the California Employer’s Guide, DE 44, to comply with subject PIT withholding and reportable PIT wages.

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 888-745-3886 (voice) or TTY 800-547-9565.

DE 1378 Rev. 34 (8-16) (INTERNET) Page 5 of 5 CU

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