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 

  Yes         Yes         Yes         Yes       
Will you pay wages 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 
 
Is this person currently performing normal and customary services in connection with the operation of your business? (If no, explain below.) 

Date       Residence Phone  

Relationship Relationship Relationship 
Social Security Number       Social Security Number       Social Security Number       Social Security Number       

Age Relationship 
 
(INTERNET)

 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 wages reportable under your election. 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. 

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