Unemployment Claim Form

Unemployment Claim Form
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
The Last Date of Employment
MonthDayYear
Date
Are you fully or partially unemployed?
FullyPartially
What is the reason of unemployment?
LayoffFurloughReduced wagesReduced hours
Has your unemployment status affected by COVID-19?
YesNo
Last Employer Name
Last Employer Name Email
example@example.com
Last Employer Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
*If you are self-employed, a business owner, or an independent contractor, list yourself as your last employer.
Signature
Clear
Date
MonthDayYear
Date
Should be Empty: