Involuntary Termination and Unemployment Claim Information Form
Please provide the following details to support your involuntary termination and unemployment claim.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employer Name
*
Job Title at Time of Termination
*
Last Day of Employment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Termination
*
Please Select
Layoff/Reduction in Force
Performance
Policy Violation
Position Eliminated
Other
Are you eligible for rehire at this employer?
Yes
No
Unknown
Have you filed for unemployment benefits?
Yes
No
In Progress
Additional Comments (optional)
Submit
Should be Empty: