For Department Use Only Date Received: Date Postmarked/Faxed: Effective Date: UNEMPLOYMENT INSURANCE APPLICATION PRE APPLICATION QUESTIONS MUST BE COMPLETED A. Were you in the military during the last 18 months? B. Did you work for an agency of the federal government during the last 18 months? C. Did you work in a state other than California during the last 18 months? D. Have you applied for unemployment insurance benefits in another state during the last 12 months? E. Did your employer or union give you a claim form for unemployment insurance benefits? Yes Yes Yes Yes No No No No Yes No If you answered NO to all of the above questions (A through E) proceed. If you answered YES to any of the above questions (A through E) do not complete this form, call 1 (800) 300-5616. PLEASE ANSWER ALL QUESTIONS ON EACH PAGE If a question is not answered or is incomplete it may delay or prevent the filing of your claim, or cause benefits to be denied. • • Please complete this form with blue or black ink only. Please print or type information. The answers you give to the questions on the application must be true and correct. You may be subject to penalties if you make a false statement or withhold information. This application will take you approximately 30 minutes to complete. 1. What is your Social Security Number as given to you by the Social Security Administration? 1. __ __ __ - __ __ - __ __ __ __ If EDD assigned you an EDD Client Number (ECN), please provide the ECN here and also provide your Social Security Number in item 2 below. (An ECN is a 9-digit number beginning with 999.) 2. List any other Social Security Numbers you have used. 2. __ __ __ - __ __ - __ __ __ __ __ __ __ - __ __ - __ __ __ __ 3. Have you ever filed a California Unemployment Insurance or Disability Insurance claim? 3. Yes No Unemployment Claim Date(s) (mm/dd/yyyy) / / / / / / a) If yes, please list for each type of claim, the most recent date(s) of when the claim(s) was filed. Disability Claim Date(s) (mm/dd/yyyy) / / / / 4. What is your full name? / / 4. Last First Middle Initial DE 1101IDUA (4-06) (INTERNET) Page 1 of 9 CU American LegalNet, Inc. www.USCourtForms.com UNEMPLOYMENT INSURANCE APPLICATION Social Security Number: __ __ __ - __ __ - __ __ __ __ 5. Is this the name that appears on your Social Security card? 5. Yes No a) Last a) If no, provide the name that appears on your Social Security card. First Middle Initial 6. List any other names you have used. 6. 7. What is your birth date? 7. __ __/__ __/__ __ __ __ (mm/dd/yyyy) 8. Do you have a Driver’s License or ID Card? 8. a) If yes, provide the name of the issuing state/entity and your Driver’s License or ID card number. 9. What is your gender? Yes a) Name of issuing state: Number 9. Male Female English 10. 10. Would you prefer your written material in English or Spanish? No Spanish a) a) What is your preferred spoken language? 11. What is your telephone number? 11. (__ __ __ ) __ __ __-__ __ __ __ 12. What is your mailing address? (Include your city, state, and ZIP code). 12. Street: City: State: __ __ ZIP Code: __ __ __ __ __ 13. Is your residence address the same as your mailing address? 13. No a) Street: a) If no, enter your residence address. (Include your city, state, ZIP code and apartment number.) A residence address cannot be a P.O. Box. Please provide a street address. 14. If you do not live in California, what is the name of the County in which you live? Yes Apt. City: State: __ __ ZIP Code: __ __ __ __ __ 14. 15. What is the highest grade of school you have completed? Check only one box. Did not complete High School High School Diploma or GED Some college or vocational school Associate of Arts Bachelor of Arts or Science Masters or Doctorate 16. Are you a Veteran? DE 1101IDUA (4-06) (INTERNET) 16. Yes No Page 2 of 9 American LegalNet, Inc. www.USCourtForms.com UNEMPLOYMENT INSURANCE APPLICATION Social Security Number: __ __ __ - __ __ - __ __ __ __ 17. List the following: a) Name(s) of all employers you worked for in the last 18 months. b) Period of employment. c) Wages earned for each employer in the last 18 months. d) How you were paid (specify hourly, weekly, monthly, annually, commission, or at a piece rate). a) Employer Name b) Dates Worked c) Earnings From: __ __/__ __/__ __ __ __ $ To: __ __/__ __/__ __ __ __ d) How Paid a) Employer Name b) Dates Worked c) Earnings From: __ __/__ __/__ __ __ __ $ To: __ __/__ __/__ __ __ __ d) How Paid a) Employer Name b) Dates Worked c) Earnings From: __ __/__ __/__ __ __ __ $ To: __ __/__ __/__ __ __ __ d) How Paid a) Employer Name b) Dates Worked c) Earnings From: __ __/__ __/__ __ __ __ $ To: __ __/__ __/__ __ __ __ d) How Paid a) Employer Name b) Dates Worked c) Earnings From: __ __/__ __/__ __ __ __ $ To: __ __/__ __/__ __ __ __ d) How Paid a) Employer Name b) Dates Worked c) Earnings From: __ __/__ __/__ __ __ __ $ To: __ __/__ __/__ __ __ __ d) How Paid 18. Employer name: 18. Which employer listed above did you work for the longest? a) What type of business was operated by the employer? (Please be specific. For example, restaurant, dry cleaning, construction, book store.) a) Type of business: b) How long did you work for that employer? b) Years c) What type of work did you do for that employer? c) 19. During the past 18 months did you work for any other employers not listed in question 17? 19. Yes Months No If yes, list the employer name, dates worked, earnings, and how you were paid on a separate sheet of paper. Attach the additional sheet of paper to this application. DE 1101IDUA (4-06) (INTERNET) Page 3 of 9 American LegalNet, Inc. www.USCourtForms.com UNEMPLOYMENT INSURANCE APPLICATION Social Security Number: __ __ __ - __ __ - __ __ __ __ Please provide information on your very last employer. This is the employer you last worked for regardless of the length of time you worked at that job, the type of work you did for that employer or whether or not you have been paid. Reminder: To file a claim, individuals must be out of work (for any reason), or working less than full time. You must provide information on the last employer you worked for as an employee. Do not include self-employment unless you have elective coverage. 20. What is the last date you actually worked for your very last employer? 20. __ __/__ __/__ __ __ __ (mm/dd/yyyy) a) What are your gross wages for your last week of work? For unemployment insurance purposes, a week begins on Sunday and ends the following Saturday. a) $ __ __ __ __ . __ __ b) What is the complete name of your very last employer? b) Name c) What is the mailing address of your very last employer? c) Mailing address: Street: ____________________________ City: _____________________________ State: __ __ ZIP Code: __ __ __ __ __ d) Is the physical address of your very last employer the same as their mailing address? (A physical address cannot be a P.O. Box. Please provide a street address.) If no, what is the physical address of your very last employer? d) Yes No Physical address: Street: ____________________________ City: _____________________________ State: __ __ ZIP Code: __ __ __ __ __ e) What is the telephone number of your very last employer at their physical address? e) (__ __ __ ) __ __ __-__ __ __ __ f) What is the name of your immediate supervisor? f) g) Why are you no longer working for your very last employer? (Lack of work includes temporary layoff, or on call status) g) Laid off, lack of work Quit Still working part time Fired Strike or lockout Briefly explain in your own words the reason you are no longer working for your very last employer, within the space provided. Please do not include any attachments. Reason: DE 1101IDUA (4-06) (INTERNET) Page 4 of 9 American LegalNet, Inc. www.USCourtForms.com UNEMPLOYMENT INSURANCE APPLICATION Social Security Number: __ __ __ - __ __ - __ __ __ __ 21. Are you unemployed as a direct result of a recent disaster in California, such as an earthquake, flood, mudslide, wildfire, etc.? If yes: 21. Yes No If yes, answer questions a-d. a) Identify the type of disaster. a) b) At the time of the disaster, in which county did you reside? b) c) At the time of the disaster, in which county did you work? c) d) At the time of the disaster, was your unemployment caused by your need to travel through the disaster county? d) Yes No If yes: Identify the disaster county or counties that prevented travel to your job. e) Circle the following that best applies to you: e) 1) An employee who is unable to work as a direct result of the disaster. 2) An individual who was scheduled to start work for an employer, but could not because of the disaster. 3) A self-employed individual who is unable to work as a direct result of the disaster. 4) An individual who intended to begin selfemployment, but could not because of the disaster. 5) An individual who became head of household as a result of the disaster. f) If you selected item 1 or 3 above, how many hours did you work per week prior to the disaster? f) g) If you selected item 3 or 4 above briefly describe how the disaster affected your ability to continue or begin your self-employment. g) h) What is the physical address of your business? h) Street: City: State: __ __ DE 1101IDUA (4-06) (INTERNET) ZIP Code: __ __ __ __ __ Page 5 of 9 American LegalNet, Inc. www.USCourtForms.com UNEMPLOYMENT INSURANCE APPLICATION Social Security Number: __ __ __ - __ __ - __ __ __ __ 22. Do you expect to return to work for any former employer? 22. Yes No 23. Are you currently self-employed, or do you plan to become self-employed? (Self-employment means you have your own business or work as an independent contractor.) 23. Yes No 24. Are you now, or have you been in the last 18 months an officer of a corporation or union or the sole or major stockholder of a corporation? 24. Yes No Yes No a) Include name of organization and your title or position. (If yes, please explain below): a) 25. Are you currently attending, or do you plan on attending school or training? 25. If yes: a) What is the starting date of the school or training? b) What is the ending date of the current session? c) What is the name of the school? d) What is the telephone number of the school? If yes, answer questions a-e: a) __ __/__ __/__ __ __ __ (mm/dd/yyyy) b) __ __/__ __/__ __ __ __ (mm/dd/yyyy) c) d) ( __ __ __ ) __ __ __-__ __ __ __ e) What are the days and hours you are attending, or plan to attend, school? e) Days and hours 26. What is your usual occupation? 26. 27. Are you available for immediate full-time work in your usual occupation? a) If no, please explain why you are not available for full-time work. 27. 28. Are you available for immediate part-time work in your usual occupation? a) If no, please explain why you are not available for part-time work. 28. 29. Are you receiving, or will you receive within the next 52 weeks, a pension other than Social Security or Railroad Retirement, which is based on your own work or wages? If yes: 29. Yes No a) Explanation: Yes No a) Explanation: Yes No a) How are you receiving your pension payments? If yes, answer questions a-e: a) Monthly Annually b) Did you pay into your pension or retirement? b) Yes No c) Did any of the employers you worked for in the last 18 months pay into the pension fund? c) Yes No d) What is the name of the company paying into the pension? d) e) Who pays the pension check to you? e) DE 1101IDUA (4-06) (INTERNET) Lump sum Unsure Page 6 of 9 American LegalNet, Inc. www.USCourtForms.com UNEMPLOYMENT INSURANCE APPLICATION Social Security Number: __ __ __ - __ __ - __ __ __ __ 30. 30. Are you receiving, or do you expect to receive, Workers’ Compensation? Yes No If yes: If yes, answer questions a-d: a) Who is the insurance carrier? a) b) What is the insurance carrier’s telephone number? b) (__ __ __ ) __ __ __-__ __ __ __ c) What is the case number, if known? c) d) What are the dates of your claim, if known? d) From: __ __/__ __/__ __ __ __(mm/dd/yyyy) To: __ __/__ __/__ __ __ __(mm/dd/yyyy) 31. Have you received or do you expect to receive, any payments from your last employer, other than your regular salary? (Example: holiday pay, vacation pay, severance pay, in-lieu-of-notice pay, etc.) Yes: No If yes, please provide the information requested in sections A-D. A. B. C. D. TYPE OF PAYMENT (Example: vacation pay) AMOUNT OF PAYMENT (Example: $600) PAID FROM (Date: MM/DD/YYYY) PAID TO (Date: MM/DD/YYYY) 32. Are you a member of a union? Yes 32. No If yes, answer questions a-f: If yes, answer questions a-f: a) What is your union name and local number? a) b) Are you in good standing with your union? b) Yes No c) Does your union look for work for you? c) Yes No d) Does your union control your hiring? d) Yes No e) Are you registered with your union as out of work? e) Yes No f) Are you going to receive strike benefits? f) Yes No 33. Do you have a date to start work? 33. If yes: a) What date will you start work? Yes No If yes, answer question a: a) __ __/__ __/__ __ __ __ (mm/dd/yyyy) 34. 34. Are you an employee of a school, educational institution, or a training facility? Yes No If yes: If yes, answer questions a-b: a) Are you returning to work in the next school session? a) Yes No b) Has your employer given you reasonable assurance, either verbal, written or implied, of returning to work for the next school session? b) Yes No DE 1101IDUA (4-06) (INTERNET) Page 7 of 9 American LegalNet, Inc. www.USCourtForms.com UNEMPLOYMENT INSURANCE APPLICATION Social Security Number: __ __ __ - __ __ - __ __ __ __ 35. Is your usual work seasonal? Yes 35. No If yes, answer questions a-c: If yes, answer questions a-c: a) When does the season usually begin? a) b) When does the season usually end? b) c) What other work related skills do you have? c) 36. Are you a U. S. citizen or national? If no: a) Are you registered with the U.S. Citizenship and Immigration Services (USCIS, formerly INS) and authorized to work in the United States? Yes 36. a) If you are registered with USCIS, answer questions b-e: Yes No No If yes, answer questions b-e: b) What is your Alien Registration Number? b) __ __ __ __ __ __ __ __ __ __ __ c) What is the expiration date of your work authorization? c) __ __/__ __/__ __ __ __(mm/dd/yyyy) d) Were you legally entitled to work in the United States for the last 19 months? d) e) What is the title and number of your USCIS document? e) Check one of the following: Yes No Alien Registration Receipt Card (1-151) Resident Alien Card (I-551) Permanent Resident Card (I-551) Employment Authorization Card (I-766) Employment Authorization Card (I-688A) Temporary Resident Card (I-688) Employment Authorized (I-688B) Arrival/Departure Record (I-94) Stamp on Visa (Stamp states: “Processed for I-551 Temporary Evidence of Lawful Admission of Permanent Residence valid until MMDDYYYY, Employment Authorized.”) THE FOLLOWING TWO QUESTIONS ARE OPTIONAL: 37. What race or ethnic group do you identify with? 37. Check one of the following: White Hispanic American Indian/Alaskan Native Cambodian Other Pacific Islander Asian Indian Korean Samoan Hawaiian I choose not to answer DE 1101IDUA (4-06) (INTERNET) Black not Hispanic Asian Chinese Filipino Guamanian Japanese Laotian Vietnamese Page 8 of 9 American LegalNet, Inc. www.USCourtForms.com UNEMPLOYMENT INSURANCE APPLICATION Social Security Number: __ __ __ - __ __ - __ __ __ __ 38. Do you have a disability? (A disability is a physical or mental impairment that substantially limits one or more life activities, such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, or working.) 38. Yes No I choose not to answer YOU MAY SUBMIT THE COMPLETED APPLICATION: By mail to the following address: By FAX to the following telephone number: EDD P.O. Box 419000 Sacramento, CA 95841-9000 1-866-215-9159 Note: Extra Postage is Required If the Department needs to verify any of the information you provide while filing a claim, you will receive additional forms by mail and will be asked to provide additional information and/or documentation. DE 1101IDUA (4-06) (INTERNET) Page 9 of 9 American LegalNet, Inc. www.USCourtForms.com