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Application For Disability Insurance Elective Coverage(DIEC)

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 Elective coverage . DIEC DIEC . Approved: 708(b) Account #. NOTE: For assistance in completing this Application , contact Effective Date: the nearest Employment Tax Office or call 888-745-3886. Subject . Quarter Upon completion of this Application , return to: Attention: Analysis Resolution and Correspondence Organization Send Forms Employment Development Department DE 2515, DE 3816DI DE 3DI Qtr(s) _____.

DE 1378DI Rev. 44 (11-16) (INTERNET) Page 1 of 4 CU Application For Disability Insurance Elective Coverage(DIEC) Complete this application only if you meet the requirements as set

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