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Voluntary Election of Coverage under the Illinois Unemployment Insurance Act 

An agreement to elect coverage becomes binding upon approval by the Director of Employment Security. If the election is 
approved, you will be notified by mail. You will similarly be notified with a statement of the reason(s) for denial.  

Type or print in ink. Sign and return original to this Department. Retain a copy for your files.  

1. Name of employer

2. Address

3. Date employer began employing workers in Illinois

4. Are you, or have you been, an employer subject to the Illinois Unemployment Insurance Act?       Yes        No 

If yes, enter the account number assigned to you

(IF YOU ARE A CURRENTLY LIABLE EMPLOYER, IT IS NOT NECESSARY TO COMPLETE ITEMS 5 THROUGH 8.) 

5. Have you incurred liability under the Federal Unemployment Act in the last five years?            Yes        No 

6. Enter the total amount of wages paid by you during the last four completed calendar quarters:

Quarter Ending:

             Wages: 

7. Enter, for each of the last 12 months, the number of persons performing services for you in Illinois, whose services
are defined as “employment” under the Illinois Unemployment Insurance Act. If a corporation, include corporate
officers.

              Month: 

No. of Workers: 

8. Give the following information with respect to each individual performing services for you on the date this election form is
being prepared. If related to owner, partner or officer, give exact relationship and to whom related; if not related, enter
“none”.

Name                                   Social Security No. Relationship and to Whom Related 

9. If you desire to extend coverage to workers whose services are excluded from the definition of “employment” under the
Act, enter below (a) the type(s) of excluded employment performed by workers whom you wish to cover, (b) the location of
the establishment(s) where such excluded employment is performed and (c) the number of workers in excluded
employment by type, in each establishment during the most recently completed week.

                         (a)                               (b)                                                        (c) 
      Type of Excluded Employment                   Location of Establishment                           No. of  Workers 

UI-1B Voluntary Election of Coverage    Page 1 of 1                                                       Rev. (0 /2011)  9

10. The undersigned employing unit does hereby elect, pursuant to the terms and provisions of Section 205(h) of the Illinois
Unemployment Insurance Act: (Check one)

a. To become an employer liable for the payment of contributions under the Illinois Unemployment Insurance Act to the
   same extent as any other employer.

b. To become an employer liable for the payment of contributions under the Act AND to extend coverage under the Act to
   workers in excluded employment.

c. To extend coverage under the Act to workers in excluded employment.

The undersigned employing unit hereby makes application for the approval of such election by the Director of Employment 
Security as of: (Check one) 
                st
 January 1  of the current year 

 The date workers were first employed in the current year 

 The following date in the present year if (c) above is checked 

Business Name: 

Signed by: 

Official title: 

Telephone: 

Date Signed: 

                  This election must be signed by owner, partner or officer.  
                  If signed by any other person, a power of attorney giving such  
                   individual authority to sign must be attached.  

For information & phone numbers, please visit,  http://www.ides.illinois.gov/SitePages/ContactIDES.aspx. 
For this & other online forms, please visit, http://www.ides.illinois.gov/forms

NOTE: Upon approval of your election by the Director of Employment Security, you will become liable for the payment of 
contributions on the wages of your workers for at least two calendar years.  

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OFFICIAL NOTIFICATION OF THE DIRECTOR’S DECISION REGARDING THIS REQUEST WILL BE MAILED TO YOU. 

This state agency is requesting information that is 
necessary to accomplish the statutory purpose as 
outlined under 820 IL CS 405/100-3200. Disclosure of 
this information may result in statutorily prescribed 
liability and sanctions, including penalties and /or 
interest.  

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