Form Ems 5203 - Voluntary Election For Unemployment Insurance Coverage printable pdf download

VOLUNTARY ELECTION FOR UNEMPLOYMENT INSURANCE COVERAGE

Use this form to request voluntary unemployment insurance coverage if your business is currently exempt

from coverage or if you have employees who are exempt from coverage.

Please complete and return this form to:

Employment Security Department

UI Tax and Wage Administration/Status

P.O. Box 9046

Olympia, WA 98507-9046

This agreement to elect unemployment insurance coverage becomes binding if we approve it. If it is

approved, we will send you a signed copy. Do not report the personnel stated below until you have

received authorization from us. If we do not approve your application, we will notify you. The

Washington Administrative Code (WAC) lists reasons why voluntary coverage may not be

approved and why it may be cancelled after it is approved (see reverse or next page).

Please answer completely each of the following questions:

1. Business name:

2. Mailing address:

3. If you are already registered with the Employment Security Department, please provide your

Employment Security (ES) Reference No. ____________________, or Unified Business Identifier

(UBI) No. ____________________.

4. Show the type(s) of non-covered employment below in which your business presently employs workers

you want covered. Also show the total number of workers in that type of employment.

Type(s) of employment to be covered (check one or specify)

No. employed

Corporate officers

All individuals

Distinct class of individuals

Other (specify)

5. Proposed effective date for coverage: _________________________.

6. _________________________________ (name of business), voluntarily elects to cover the workers

indicated who would not otherwise be covered for unemployment insurance. I request written

approval of coverage under RCW 50.24.160. I am a corporate officer or business owner and am

authorized to represent the business.

____________________________________________

(Signature of corporate officer or business owner)

(Business phone)

(Title)

(Date of application)

7. This application MUST be signed by a corporate officer or business owner. Voluntary coverage is

effective until terminated by you or cancelled by us. A request for termination by the employer must

be in writing and postmarked by January 15, immediately following the end of the last year of desired

coverage. In the event that your taxes become delinquent, we reserve the right to cancel your

voluntary coverage. Coverage must remain in effect for a minimum of two calendar years.

Approved by the Commissioner of Washington Employment Security Department effective ____________.

_______________________________________________

(Date of approval)

(Authorized representative of the commissioner)

(See reverse or next page)

EMS 5203 (Rev. 4/09)

Form Ems 5203 - Voluntary Election For Unemployment Insurance Coverage

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