Transcription of Application For Disability Insurance Elective Coverage(DIEC)
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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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