Sample Application: Questions asked on the Internet Application for Benefits

Sample Application: Questions Asked on the Internet Application for Benefits

NOTE:
You are strongly encouraged to read the Internet Claim
Frequently Asked Questions before you continue.

You will be asked the following questions on the application. In preparation for completing the application you should review these questions and prepare your answers. If you have a printer, you can print out this page and use it as a worksheet.

You will complete the application in steps; each step is a separate page that will load into your browser. Those steps and the questions on each of the steps are represented here.

You must answer all questions marked with a dark red asterisk

. If you do not answer, your application will not be processed.

Whenever you see a small "Help" button --

-- click on it to open up a small window that will assist you with that question.

Many of the buttons on this form have been disabled. However, you will be able to use all of the Help buttons, the Search button on the referral union question, and the Salary Calculator buttons on the Add Employer pages.

When you have finished reviewing the questions, clicking the "Return to Application" button at the bottom will close this browser window and return you to the application process.

1. File an Unemployment Insurance Claim

Social Security Number:
Please re-enter your Social Security Number:
Giving false information in order to receive unemployment benefits is against the law. If you do not honestly and accurately respond to all questions in this application, you may be disqualified from receiving benefits. You may also be charged with a crime and subjected to criminal penalties under RCW 50.36.010 or Chapter 9A.72 RCW. When you apply for Unemployment Insurance Benefits we will verify your Social Security Number through a computer match with the Social Security Administration. If there is a question about the Social Security Number, we will not pay benefits until the question is resolved. Click "I Agree" to certify you have read, understand, and accept these conditions. If not, click "I Disagree" to exit without filing your unemployment insurance application.

2. Contact Information

Last Name:	____________________________________
First Name:	____________________________________
MI:	_______
Previous Last Name (if used in last five years):	____________________________________
Mailing Address:	____________________________________
Additional Address (Apt#, Lot#, etc.):	____________________________________
City:	____________________________________
State or Canada
ZIP	______________ ____________
Telephone: (including area code)	(________) ________ ________
Email:	____________________________________
Do we have your permission to contact you or leave detailed information about your claim by

3. Personal Information

Date of Birth: (mm dd yyyy)

____________ _______________ ____________

Gender

Female Male

Highest Level of Education:

Ethnic:

Language Preference:

Veteran Status:

Are you disabled?

Yes No Choose not to answer

*If you are a veteran and* you answer "yes", an additional field will appear:**
Do you have a service-connected disability?

Are you a US citizen or National?

Yes No

If you answer "no", four additional fields will appear:
Were you legally entitled to work in the United States in the last 24 months?	Yes No
Alien Registration Number:	A ______________________
Document type:
Expiration Date:	_________ __________ __________
Document Description:	_____________________________________________

Do you currently have an anti-harassment
order issued for your protection?

Yes No

If you answer "yes", two additional fields will appear:
Start Date (mm dd yyyy):	__________ __________ __________
End Date (mm dd yyyy):	__________ __________ __________

4. Eligibility Information

Have you filed for Unemployment Benefits in any state other than Washington in the last 12 months?

Yes No

If you answer "yes", an additional field will appear:
Select the state in which you filed:

Do you get your work through a Union?

Yes No

If you answer "yes", a search button will appear. Click on it to locate your union.

Are you receiving a Union Pension?

Yes No

If you answer "yes", two additional fields will appear:
Monthly Amount:	$_______ . ____
End Date (mm dd yyyy):	__________ __________ __________

Are you starting work for a new employer before [ date ]?
Note: This is a dynamically calculated date that is the
Sunday five weeks from the Sunday date of the week
you are filing this claim.

Yes No

If you answer "yes", two additional fields will appear:
Employer Name:	__________________________________
Start Date (mm dd yyyy):	__________ __________ __________

Note: Unemployment benefits received are taxable for federal income tax purposes.

Do you want the department to withhold 10% of your UI benefits and send it to the IRS?

Yes No

If your claim is based entirely on part-time work of 17 or fewer hours each week, you may be eligible for benefits even if you are only looking for part-time work.

Did you work 17 or fewer hours each week during the one-year period beginning [ date ] and ending [ date ]?
Note: These are dynamically created dates which
show your base year. If you file your application in
a different calendar quarter, these dates will change.

Yes No

To be eligible to receive your unemployment benefits, you must be able to work, available for work, and actively seeking work.

Are you currently enrolled in a school or training program?

Yes No

Do you plan to enroll in school or training by [ date ]?
Note: This shows a dynamically created date which is
45 days from today. If you file your application on a
different day from today, this date will change.

Yes No

If you answer "yes", an additional field will appear:
Enter date you plan to enroll in school or training (mm dd yyyy):	__________ __________ __________

Is there any reason you cannot seek or accept full-time work?

Yes No

If you answer "yes", these additional fields will appear:
Please check as many as apply: Medical, Self Medical, Other Family Member No Childcare No Transportation If Other, briefly explain: __________________________________________________________

5. Employment History

You will be taken to an Employment History screen that displays a list of employers. You should see the employers you have worked for, but for security purposes you will also see a number of employers that you have never worked for. Choose your employer from the list and you will be taken to the Washington Employment screen.

If your employer was not on the list, you can select the "Add Washington Employer" button below and fill in the blanks on the next screen. If you had US Military or Federal civilian employment, you can select the appropriate buttons below and fill in the blanks on those screens as well.

You must provide employment details for all work you performed since [ date* ], including federal civilian employment and service in the U.S. Military. Work you performed for a regular employer must have been in the State of Washington. If you worked in another state, or worked in two or more states, you cannot file your claim over the Internet. Please call your closest Unemployment Claims TeleCenter.

[* Note: This is a dynamically created date that marks the beginning of the calendar quarter two years ago.
If you file your claim in another quarter, this date will be different.]

The table below contains names of employers for whom you have worked. We have included additional employers for security purposes. Start by clicking "SELECT" for one employer for whom you have worked. You will be taken to an Employer Input Page where you will add some details for your job with this employer. Continue selecting your other employers in the same way. When all of your employers are displayed in the work history, click the check box for "My Work History is Complete", then "Click Here to Continue".

6. Primary Occupation

After you finish selecting all of your employers, you will be taken to a screen where you can select your primary occupation.
Your unemployment claim is based upon work you performed during a specific period of time. The occupation in which you earned the most wages since [ date ] is called your "Primary Occupation". Note: This is a dynamically created date which marks the beginning of your base year. If you file your application in a different calendar quarter, this date will be different. In the window below, please enter the name of your primary occupation, then click the "Search" button. A window will open with a list of possible occupations. Click on the correct occupation. A window will open with a short description of the occupation you chose. If all the information is correct, click the "Click Here to Continue" button. You will be taken back to the application, along with the code number that we need. If you want to begin another search for your primary occupation, click the "Search" button again and repeat the process described above.
Enter your primary occupation:	_____________________________

7. Internet Unemployment Claim Summary

You will see a summary of all of the entries you've made on the application. You should check these over carefully for accuracy. If you find an error, you will be able to link back to the page and correct it.

At the end of the summary, you will see the following:

You are required to read and certify to these six items before your application will be accepted.

By submitting this Application for Service, I hereby register for work and/or request an initial determination of benefits potentially payable to me under the Washington Employment Security Act and/or Federal Unemployment Compensation Act.
I know that the law provides penalties for false statements made in connection with this claim. I certify under penalty of perjury that the information that I have provided on this application is accurate.
In accordance with the provisions of the Privacy Act of 1974, I authorize my former employer(s) to release all information requested in connection with my claim for unemployment compensation.
I am furnishing my Social Security Number as required by federal law as a condition of eligibility for benefits.
I understand that the Employment Security Department may share information about me with other agencies such as the US Internal Revenue Service and the state Department of Social and Health Services Office of Child Support, as required by federal law.
I understand I will receive an "Unemployment Claims Kit" in the mail and that I must read this booklet.