Keep This Form
Please ensure that you read both sides of this form prior to ling a claim for unemployment benets. If
you become unemployed, this information may help to determine your unemployment benet entitlement.
When to le a claim for unemployment benets:
A claim for unemployment benets begins the week it is led. Therefore, you should le your claim for
benets during your rst week of unemployment.
To receive unemployment benets, you must both be eligible and qualied. You must:
File a claim, and report for benets as directed by Unemployment Insurance (UI).
Register for work each time a new, additional or re-opened claim is led as directed by UI.
Have sufcient earnings in the past 18 months.
Be able to work.
Be available for work. You must immediately inform UI of any changes to your contact information
(mailing address and telephone number).
If directed by UI, appear at a specied location provided in a mailed notice for an evaluation of your
eligibility for unemployment benets.
If requested by UI, provide a statement of wages (wage afdavit) for purposes of calculating your
unemployment benets as state law requires that you produce evidence of those wages (pay stubs,
W-2, employer payroll records, etc.).
Be actively engaged in seeking work.
Conduct a systematic and sustained work search effort and provide proof of those efforts by submitting
your work search efforts as directed by UI.
To le a claim for benets, you will need the following:
1. This form and any similar forms you received from any employer in the past 18 months, or pay
stubs with employer name, employer payroll record, or W-2 Form.
2. Your Social Security number, complete mailing address (zip code), telephone number, and county
of residence.
3. Your driver’s license or state identication card.
4. Your Alien Registration Number and the expiration date of your work authorization if you are not a
citizen or national of the United States.
5. Name(s) of employer(s), date(s) of employment, and reason for separation from each employer
you worked for in the past 18 months.
6. Information from your nancial institution if you choose to have your benets directly deposited
into your checking or savings account.
UIA 1711
(Rev. 05-18)
Authorized by
MCL 421.1 et seq.
TED is an equal opportunity employer/program.
Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.
UIA 1711
(Rev. 05-18)
Filing Claims on the Internet
You may le your new, additional, or reopened claim on UI website at Select
Michigan Web Account Manager (MiWAM)” logo to sign up for a web account with UI. You do not have
to have a MiWAM account to le a claim. However, if you do have a MiWAM account, rst login, click on
the “Michigan Web Account Manager for Claimants and Employers” link and select the “File a claim” link
under the ling options. You may le your claim through the Internet if all of the following requirements
are met:
You have worked under only one Social Security number.
You have not led a claim for unemployment benets against another state during the past 12
Before ling online, ensure you have the information from Items 1 through 6, a pen or pencil, and paper
to make notes of information you will receive from UI. You can write the information you need on this
form so that it is available when you le your claim.
The Internet Filed Claim system is available 24 hours a day, 7 days a week, regardless of the last two
digits of your Social Security number.
If you have a question about your claim, you can call UI at 1-866-500-0017 (TTY customers use
1-866-366-0004). UI sta is available to assist you from 8:00 a.m. to 4:30 p.m., ET, Monday through
To Be Completed by the Employer
Rule R 421.204 of the Michigan Administrative Rules requires that a completed copy of this form, or an
equivalent written notice, be given to each employee before, or when he/she is separated from your
employ. A $10.00 penalty for non-compliance with this rule may be imposed by UI. Complete the following
information in the spaces below.
Your 10-digit UI Account Number:___________________________
Your 9-digit Federal Identication Number:____________________
Employers Name with Doing Business As (DBA), and complete mailing address where wage
and separation information is available for the worker listed on this form.
__________________________________________ _______________________________________
Name DBA
__________________________________________ _______________________________________
Address for Employment City, State, Zip Code
__________________________________________ _______________________________________
Name of Contact Person Telephone Number
Reason for Separation
Direct any questions to the Oce of Employer Ombudsman (OEO) through your MiWAM
account at or call 1-855-484-2636. TTY customers call 1-866-366-0004.
File Claims by Telephone
Call MARVIN at 1-866-638-3993 anytime Monday through Saturday, 8:00 a.m. to 7:00 p.m.
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