Unemployment Insurance Application Form

Unemployment Insurance Application Form
Full Name *
First NameLast Name
Gender (Female/Male)*
Date of Birth*
MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Have you filed an unemployment or disability insurance claim in this state in the recent two years?*
YesNo
Date(s) of Unemployment Claim*
MonthDayYear
Date
Date(s) of Disability Claim *
MonthDayYear
Date
Have you spent the last 18 months working in this state?*
YesNo
Have you spent the last 18 months working in another state?*
YesNo
Please choose.
Please explain how do you go about looking for work and getting to work if you have it?*
What is the highest school grade you have received?*
Didn't finish high schoolHigh School Diploma or GEDBachelor of Arts or ScienceMasters or DoctorateOther
Have you served in the military?*
YesNo
Please provide information on your employment and wages for the last 18 months below. Your pay may have been reported under a corporate name if you worked for a temporary agency, a labor contractor, an agent for actors or actresses, or an employer where wages are reported under a corporate name. To find out who your employer is, look through your check stubs or W-2 forms.
Employer Name*
First NameLast Name
Employer Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Start Date*
MonthDayYear
Date
End Date*
MonthDayYear
Date
Total Wage
How were you paid?*
WeeklyMonthlyYearlyOther
How did you work?*
Part-timeFull-time
If you worked for any other employers in the last 18 months, please provide the same information above, for your other previous employers and attach here.
Cancelof
What do you usually do for a living? Please explain.
Is your primary source of income seasonal?*
YesNo
Start Date*
MonthDayYear
Date
End Date*
MonthDayYear
Date
Within the area provided, briefly explain why you are no longer working in your own words.*
Do you presently work for or plan to work for a school or educational institution, a public or nonprofit employer, or any other organization that does school-related work?*
YesNo
Please explain.*
Do you feel like you're in a lull or that you've gotten off track?*
YesNo
Do you have reasonable assurance from any school or educational institution that you will be able to return to work following the recess or off track period?*
YesNo
Do you intend to return to any of your previous employers?*
YesNo
Do you have a firm start date with any potential employers?*
YesNo
Start Date*
MonthDayYear
Date
Are you a member of a labor union or a non-labor trade group?*
YesNo
What is the name of organization?*
What is the number of your union's local?*
Is your union or non-union trade group able to help you find work?*
YesNo
Is your hiring influenced by your union or non-union trade association?*
YesNo
Are you unemployed and registered with your union or non-union trade association?*
YesNo
Are you immediately available for full-time work in your current occupation?*
YesNo
Please explain why you are unable to work full-time.*
Are you immediately available for part-time work in your current occupation?*
YesNo
Please explain why you are unable to work full-time.*
Are you planning to start your own business in the future?*
YesNo
In the recent 18 months, did you serve as an elected public officer or a Governor-exempt appointee?*
YesNo
Do you have a pension right now?*
YesNo
Will you be receiving any additional pension(s) in the coming year?*
YesNo
Do you currently receive or intend to receive Workers' Compensation?
YesNo
Have you received or anticipate receiving any payments from your previous company in addition to your normal salary? (Examples include holiday compensation, vacation pay, severance pay, notice money, and so on.)*
YesNo
Please enter the information below.
Payment Type Amount Start Date End Date
Payment 1
Payment 2
Payment 3
Are you a citizen or a national of the United States?*
YesNo
Are you authorized to work in the United States and registered with the US Citizenship and Immigration Services?*
YesNo
Were you able to work legally in the United States for the previous 19 months?*
YesNo
Are you unemployed because of a recent calamity in your state, such as an earthquake, flood, mudslide, wildfire, or other natural disaster?*
YesNo
Please explain the disaster.*
Signature*
Clear
Date Signed*
MonthDayYear
Date
Should be Empty:

	Payment Type	Amount	Start Date	End Date
Payment 1
Payment 2
Payment 3