Membership Application

If your organization is a reimbursing employer, please provide the information requested below. Reimbursing employers receive a bill from the state for unemployment benefit charges. As opposed to contributing employers, who have a quarterly tax rate.

Taxable payroll is the first $9,500 each employee earns per year. Benefit charges should equal the amount of money you reimbursed to the unemployment agency.

Your completed application must be accompanied by the following items:

We hereby apply for membership in the group plan, effective January 1, pursuant to the terms and conditions set forth in the By-laws of the corporation and other applicable rules and regulations as adopted by the Board of Directors from time to time. This application also provides 501 Alliance with authorization to obtain information about our current employer account with the unemployment agency for the purposes of evaluating our qualifications for membership if necessary.

CERTIFICATION: I hereby certify that, to the best of my knowledge and belief, this application is a true and complete statement, prepared from the records of the above employer.