ࡱ> VXU'` LbjbjLULU 54.?.? M80\?333IL(t-(>$@hoB>^3>=>d y; ]S|<>0?BvBB(3rE\N333>>EX333?$ MAINE DEPARTMENT OF LABOR Bureau of Unemployment Compensation EMPLOYER'S ELECTION TO COVER MULTI-STATE WORKERS UNDER THE MAINE EMPLOYMENT SECURITY LAW Employer's Full Name Employer Account No.  Address (Street, City, State, ZIP Code)  The above employer, which employs workers in more than one state, hereby elects to insure the following workers against unemployment under the Employment Security Law of fb88. Such individuals are named below in item 2. This election is subject to approval by all the affected states. 1. The employer accordingly requests the fb88 Bureau of Unemployment Compensation to enter into a reciprocal coverage agreement with each of the following states or jurisdictions in which the individuals named under item 2 may do some work for the employer and under whose employment security laws they might otherwise be covered: (If more space is required, use plain paper and attach.) (a) (d) (g) (b) (e) (h) (c) (f) (i)  TO EMPLOYER: Send two (2) copies of this form for each jurisdiction you list above, plus two (2) more, all signed, to the fb88 Department of Labor, Bureau of Unemployment Compensation, 47 State House Station, Augusta, ME 04333-0047. Thus, if five (5) jurisdictions were listed, you should submit ten (10) copies, plus two (2) more, or a total of twelve (12) signed copies.  2. List of workers covered by this election: (If more space is required, use plain paper and attach.) NameSocial Security No.* Basis for Election in fb88Residence (State) * Under "Basis for Election in fb88," enter "work" or "residence" or "place" to show respectively that the worker "does some work there," or "has his residence there," or that you "maintain a place of business there. 3. Employer's Business: 4. The employer has a place of business in the following States listed above: 5. Type of work to be performed by the individuals listed under item 2: 6. Employer's reason for requesting coverage in fb88: 7. The employer requests that this election become effective as of the beginning of the calendar year 8. This election, if approved, shall remain operative as to the individuals listed herein until terminated in accordance with the currently applicable termination section of the fb88 Employment Security Law. 9. The employer hereby agrees to give each individual covered by this election, promptly after its approval, a copy of the approval. 10. The employer hereby agrees to comply with any requirements applicable to this election under the fb88 Employment Security Law. 11. To prevent this election from denying unemployment compensation coverage to workers not listed hereon, the employer hereby agrees with each interested jurisdiction approving this election that it may count the workers covered by this election, and their wages, as if this election did not apply, for the purpose of determining whether the employer is covered by each interested jurisdiction's unemployment law. Signed, for the Employer, By:TitleDate   APPROVAL BY MAINE DEPARTMENT OF LABOR, BUREAU OF UNEMPLOYMENT COMPENSATION This election is hereby approved, in accordance with subsection 12 of section 1082 of the fb88 Employment Security Law, as submitted by the electing employer. By: Title:Date:     Me. FX-RC1 (rev. 06/2011) > > > CONTINUE ON REVERSE SIDE < < < ? 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