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Employer Election To Cover Multi-State Workers
Under The Illinois Unemployment Insurance Act
Fax Number: 217-557-1948 33 South State Street, Chicago, IL 60603
Employer’s Name ______________________________ Illinois Account Number ______________
FEIN ________________________
Address ______________________________________________________________________________
(Street) (City) (State) (Zip Code)
Telephone Number ______________________
The employer requests that the Illinois Department of Employment Security enter into a reciprocal
coverage arrangement with each of the following other States where individuals named under Item
2, on the RC-1 form may do some work for the employer and under whose unemployment insurance
laws they may be covered:
(j) __________________ (k) __________________ (l) ________________
(m)__________________ (n)___________________(o)________________
(p)___________________(q)___________________(r)________________
(s)___________________ (t)___________________ (u)_____ __________
(v)__________________ (w)___________________(x)________________
(y) __________________ (z)____________________
Basis for Election in Illinois:
(A). If any part of the individual’s services are performed in Illinois, enter “work” under the reason below.
(B). If the individual has his residence in Illinois, enter “residence” under the reason below.
(C). If the employer maintains a place of business in Illinois and the employee does not reside in or perform
services in another jurisdiction where the employer is liable, enter “place” of business under the reason below.
Name Social Security Number State of Employee Base Reason
Residence of Operation
RC-1A (Rev. /9 2017)
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