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Human Resources and Skills Development Canada Ressources humaines et D veloppement des comp tences Canada APPLICATION FOR EMPLOYMENT INSURANCE PREMIUM REDUCTION - For assistance see the guide called The Employment Insurance Premium Reduction Program which is available online at www. servicecanada.gc.ca/prp. - You must complete an application form for each payroll account for which you require a premium reduction. - You must include a copy of each short-term disability plan you want to register. Human Resources and Skills Development Canada Ressources humaines et D veloppement des comp tences Canada APPLICATION FOR EMPLOYMENT INSURANCE PREMIUM REDUCTION - For assistance see the guide called The Employment Insurance Premium Reduction Program which is available online at www. servicecanada*gc*ca/prp* - You must complete an application form for each payroll account for which you require a premium reduction* - You must include a copy of each short-term disability plan you want to register. For details see page 5 in the guide. R Payroll account P Company name Mailing address City Prov* Postal code 1. Specify how many employees reported under the payroll account indicated above are covered by your short-term disability plan s. 2. If you have employees indicated in question 1 for whom you remit Quebec Parental Insurance Plan premiums indicate the number. Returning the employees portion of the savings See page 6 in the guide. 3. Five-twelfths 5/12 of the savings from the premium reduction belongs to the employees to whom the reduced rate applies. As the employer you are required to return this amount to the employees. How will you return this portion of the savings By signing this application I declare that the employees portion as indicated above - is at least equal to 5/12 of the savings - is a new benefit or an enhancement to an existing employee benefit - is accessible to all employees to whom the reduced rate applies and - will be provided in the year for which the reduction is given or within the first four months of the following year. Note If you and your employees have signed a mutual agreement on how you will return their part of the savings 5/12 or if the details of the method used are contained in a collective agreement please include a copy of the relevant document with this application* I declare that the information provided on this form is true and accurate to the best of my knowledge. Title Name of authorized contact please print - Fax Signature Tel* Please return this form along with any other required documents to You may call us at 1-800-561-7923 EI Premium Reduction Program PO Box 11000 Bathurst NB E2A 4T5 For office use only HRSDC NAS5022 2010-03-002 E Date Fax 506-548-7473 File Request date Disponible en fran ais NAS 5022F Date sent. servicecanada*gc*ca/prp* - You must complete an application form for each payroll account for which you require a premium reduction* - You must include a copy of each short-term disability plan you want to register. For details see page 5 in the guide. R Payroll account P Company name Mailing address City Prov* Postal code 1.

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