HomeMy WebLinkAbout32052Agreement No. 15-190
~ Employment
EDD Development
Department
California
Taxpayer Assistance Center, Attention: Specialized Covera e Desk, P.O. Box 2068, Rancho Cordova, CA 95741-2068,916-654-6288
For Department Use Only
Account No. 7 7 6 50 0 9 -1
Statistical Code---------------
Effective Date---------------
Application for Elective Coverage of State Disability Insurance* ONLY Approved By---------------
IMPORTANT
Date------------------
Employer Notified----=--:-:---------
(Date) Send ______________________________ __
Number of Employees
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 you wish to apply for State Disability Insurance coverage ONLY for
your employees under Section 702.6, 71 0.4, 71 0.5, 71 0.6, or 710.9 of the CUIC. Coverage under these sections of the CUIC does
not make provision for Unemployment Insurance benefits.
Complete this form only for:
1. Employing units with eligible employees who are California residents whose services are covered by the unemployment
compensation laws of another state that does not have a disability insurance program under Section 702.6 of the CUIC.
OR
2. Employees of any of the following:
• A public school employer under Section 71 0.4 of the CUI C.
• A public agency employer under Section 710.5 of the CUI C.
• An Indian tribe under Section 71 0.6 of the CUI C.
• A community college district under Section 710.9 of the CUI C.
NOTE: If your application is approved, the elective coverage agreement will be subject to all of the requirements and conditions
outlined in the Information Concerning Elective Coverage for State Disability Insurance ONLY Under Section 702.6,
710.4, 710.5, 710.6, or 770.9 of the California Unemployment Insurance Code (DE 1378P) form. Please retain your copy
of the DE 13 78P for reference.
******************
Please Type or Print
1. Name of Employer County of Fresno
2. Business Address 2220 Tulare St., 14th Flr. I Fresno I Fresno
(Number and Street) (City) (County)
(559) 600-1810
(Phone)
CA
(State)
93721
(ZIP Code)
3. Mailing Address _(~S:.::a"-'m"'e::.l,___ ______________________________________ _
(Number and Street) (City) (County) (State) (ZIP Code)
4. Type of Employer-(Check one)
0 Employing Unit With Eligible Employees-Section 702.6
0 Public School-Section 710.4 0 Indian Tribe-Section 710.6
Ill Public Agency-Section 710.5 0 Community College District-Section 710.9
5. Law under which agency/employer was established. (Does not apply to Indian Tribes.) Charter County established in 1856
(a) California General Laws pursuant to California Constitution.
Title of Act N A Number Year Enacted OR -----
(b) California Codes
Title of Code _,_N'-'-'-A"------------Number---------
Sections to _________ _
6. Members of governing body of the employer.
Name
Deborah Poochigian
Andreas Borgeas & Henry Perea
Buddy Mendes & Brian Pacheco
*Includes Paid Family Leave (PFL).
DE 1378N Rev. 13 (12-13) (INTERNET)
Title
Chair, Board/Supervisors
Member, Board/Supervisors
Member, Board/Supervisors
Page 1 of 2
Part __ _ Chapter __
Residence Address
cu
7. This application covers employees of the following appropriate units:
Show Name of Bargaining Unit or Describe Type of Services
D Bargaining Unit
Ill Management Management and Senior Management employees
D Confidential
D Unrepresented
D Academic
D Other
8. Complete this schedule covering all elected officers and appointees who perform services for the agency named in Item
1. Exclude individuals listed in Item 6.
(a) Elected offices: (These individuals are ineligible for coverage.)
Title of Position
(b) Person holding appointive positions: (These individuals are eligible for coverage unless appointed to fill a vacant
elected office.)
Title of Position
No. of Positions
in this Category By Whom Appointed
No. of Such Individuals
Desiring Coverage
(c) Total number of employees to be covered (excluding elected officers and those appointed by the Governor).
9. Deductions should not be made from your employees' wages for the purpose of paying employee contributions required
under the CUIC until your election is approved.
10. 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.
0 First day of current quarter Ill First day of next quarter
11 . Attach a copy of either:
• The negotiated agreement between the employer and the recognized employee organization Q[ written petition signed
by a majority of the eligible employees to be covered by the election under Section 702.6 of the CUIC.
OR
• The resolution in which the governing body described in Item 6 approved the filing of an application for elective
coverage under Section 71 0.4, 71 0.5, 71 0.6, or 710.9 of the CUIC.
******************
The employing unit with eligible employees or governmental or tribal entity described in Item 1 hereby files its application
under Section 702 .6, 71 0.4, 71 0.5, 71 0.6, or 710.9 of the CUIC to become an employer subject to the CUI C. It is understood
that upon approval of the election by the Director, the Employing Unit/Public School/Public Agency/Indian Tribe/Community
College District will be an employer subject to the CUIC for State Disability Insurance purposes ONLY to the same extent as
other employers as of the date specified in the approval, and will remain a subject employer for at least two complete calendar
years and thereafter, until this election is terminated as provided by the CUIC.
I declare that this application has been examined by me, and to the best of my knowledge, it is true and correct and made in
good faith under the provisions of the CUI C. ,.f\ l 1 . ~
Thl> docl.,oVoo must be slgoed by ooe ISlgoedJ ~ {L Date hiJqJ b
or more individuals shown under Item 6. (Signed) __ Date ~ ___ P ___ _
(Signed) Date-------
DE 13 78N Rev. 13 (12-13) (INTERNET) Page 2 of 2 cu