CLAIMANT SEPARATION STATEMENT – VOLUNTARY QUIT
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Explain the attempts you took to resolve the problem.
If you quit for a medical reason, explain your medical problem, when it began and its effects
upon your ability to perform your duties.
Are/Were you under a physician’s care? YES NO
If YES, Physician’s Name
Were you advised by your physician to quit your job?
If YES, when and why?
NO Was the reason for your quitting any of the following? YES
If YES, select all that apply.
a. I was diagnosed with Coronavirus Disease 2019 (Covid-19) or was experiencing symptoms
b. A member of my household was or had been diagnosed with Covid-19.
c. I was providing care for a family or household member who was diagnosed with Covid-19.
d. A child or other person I care for is unable to attend school or an
other facility as a result of
e. I have become the breadwinner or major support for a household because the head of the
household has died as a direct result of Covid-19. (Please provide the death certificate.)
f. I was unable to reach my place of employment because of a quarantine imposed as a result of
the Covid-19 public health emergency.
g. I quit my previous job to perform self-employment services or work as an independent
contractor and Covid-19 has severely limited my ability to perform my normal work.
h. I was scheduled to start a job with a new employer, but I could not start that job, or the offer
was withdrawn as a result of Covid-19.
i. I quit to work for a new employer, but that place of employment was closed due to Covid-19.
j. I had to quit my job, was laid off, or had my work hours reduced as a result of Covid-19.
I HAVE MADE THIS STATEMENT FOR THE PURPOSE OF OBTAINING UNEMPLOYMENT BENEFITS KNOWING
THAT THE LAW PROVIDES PENALTIES FOR FALSE STATEMENTS OR WITHHOLDING OF INFORMATION.
Please provide any other reason(s) the UI Division should consider in the determination process.