Fillable UNEMPLOYMENT INSURANCE APPLICATION (California)

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UNEMPLOYMENT INSURANCE APPLICATION (California)

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UNEMPLOYMENT INSURANCE APPLICATION
FILING INSTRUCTIONS
Complete this application including any applicable attachment(s). Print or type the information. Use blue or black ink only.
Answer all questions on each page. Review your application thoroughly for completeness. An incomplete application may delay
or prevent the ling of your claim, or cause benets to be denied. If the Employment Development Department (EDD) needs to
verify any of the information you provide while ling a claim, you will receive additional forms by mail and will be asked to provide
additional information and/or documentation.
APPLICATION QUESTIONS
The answers you give to the questions on this application must be true and correct. You may be subject to penalties if you make a
false statement or withhold information.
1. Did you work in a state other than California during the
last 18 months?
AND / OR
Did you work in Canada during the last 18 months?
1. Yes No If yes, check the applicable box(es) below:
State(s) Outside California, specify state(s):
Canada
2. What is your Social Security number as given to you
by the Social Security Administration?
a) If the EDD assigned you an EDD Client Number
(ECN), please provide the ECN here. (An ECN is a
9-digit number beginning with 999 or 990.)
2.
a)
2A. List any other Social Security numbers you have used. 2A.
3. What is your full name? 3. Last
First
Middle Initial
4. Is this the name that appears on your Social Security
card?
a) If no, provide the name that appears on your
Social Security card.
4. Yes No
a) Last
First
Middle Initial
5. List any other names you have used. 5.
6. What is your birth date? 6. (mm/dd/yyyy)
7. What is your gender?
7. Male Female
8. Would you prefer your written material in English or
Spanish?
a) What is your preferred spoken language?
8. English Spanish
a)
9. Have you led a California Unemployment Insurance
or a Disability Insurance claim in the last two years?
a) If yes, list each type of claim and the most recent
date(s) of when the claim(s) was led.
9. Yes No
a) Unemployment Claim Date(s) (mm/dd/yyyy)
a) Disability Claim Date(s) (mm/dd/yyyy)
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DE 1101ID Rev. 5 (5-21) (INTERNET) Page 2 of 12
UNEMPLOYMENT INSURANCE APPLICATION
Social Security number: – –
10. Do you have a Driver License issued to you by a
State/entity?
a) If yes, provide the name of the issuing State/entity
and your Driver License number.
If no, answer questions b-d:
b) Do you have an Identication Card issued to you
by a State/entity?
c) If yes, provide the name of the issuing State/entity
and your Identication Card number.
d) How do you look for work and, if you have work,
how do you get to work?
10. Yes No
a) Name of issuing State/entity:
Driver License Number:
If no, answer questions b-d:
b) Yes No
c) Name of issuing State/entity:
Identication Card Number:
d) Please Explain:
11. What is your telephone number?
a) If you are deaf, hard of hearing, or have a speech
disability and use TTY or California Relay to
communicate, check the appropriate box.
11. – –
a) TTY (Non-voice) California Relay Service
12. What is your mailing address?
(Include your city, State, and ZIP code)
12. Street: Apt.:
City:
State: ZIP Code:
13. Is your residence address the same as your mailing
address?
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.
13. Yes No
a) Street: Apt.:
City:
State: ZIP Code:
14. If you do not live in California, what is the name of the
County in which you live?
14.
15. What race or ethnic group do you identify with? Check one of the following:
White Black not Hispanic Hispanic
Asian American Indian/Alaskan Native Chinese
Cambodian Filipino Other Pacic Islander
Guamanian Asian Indian Japanese
Korean Laotian Samoan
Vietnamese Hawaiian I choose not to answer
16. 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.)
16. Yes No I choose not to answer
17. 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
18. Are you a Military Veteran?
18. Yes No
1101I02
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UNEMPLOYMENT INSURANCE APPLICATION
Social Security number: – –
19. Provide your employment and wages information for the past 18 months. If you worked for a temporary agency, a labor contractor, an
agent for actors or actresses, or an employer where wages are reported under a corporate name, your wages may have been reported
under that employer name. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer.
a) Name and mailing address of all employers you worked for in the last 18 months.
b) Period of employment (Dates Worked).
c) Total Wages earned for each employer in the last 18 months.
d) How you were paid (specify hourly, weekly, monthly, annually, commission, or at piece rate).
e) Specify if you worked full-time or part-time.
f) How many hours you worked per week.
g) Check the appropriate “Yes/No” box if the employer is (or is not) a school or educational institution or a public or nonprot employer
where you performed school-related work.
NOTE: It is important that you report the employer name(s) and mailing address(es), period(s) of employment, and wages correctly. Failure to
provide complete information will result in your benets being delayed or denied.
a) Employer Name and Mailing Address b) Dates Worked c) Total Wages d) How were you paid?
(e.g.,weekly, monthly, etc.)?
Name: From: $
Mailing Address: To:
Street:
City:
State: ZIP Code:
e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?
g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No
If yes, provide phone number: – –
a) Employer Name and Mailing Address b) Dates Worked c) Total Wages d) How were you paid?
(e.g.,weekly, monthly, etc.)?
Name: From: $
Mailing Address: To:
Street:
City:
State: ZIP Code:
e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?
g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No
If yes, provide phone number: – –
a) Employer Name and Mailing Address b) Dates Worked c) Total Wages d) How were you paid?
(e.g.,weekly, monthly, etc.)?
Name: From: $
Mailing Address: To:
Street:
City:
State: ZIP Code:
e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?
g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No
If yes, provide phone number: – –
a) Employer Name and Mailing Address b) Dates Worked c) Total Wages d) How were you paid?
(e.g.,weekly, monthly, etc.)?
Name: From: $
Mailing Address: To:
Street:
City:
State: ZIP Code:
e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?
g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No
If yes, provide phone number: – –
1101I03
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UNEMPLOYMENT INSURANCE APPLICATION
Social Security number: – –
19. Continued
a) Employer Name and Mailing Address b) Dates Worked c) Total Wages d) How were you paid?
(e.g.,weekly, monthly, etc.)?
Name: From: $
Mailing Address: To:
Street:
City:
State: ZIP Code:
e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?
g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No
If yes, provide phone number: – –
a) Employer Name and Mailing Address b) Dates Worked c) Total Wages d) How were you paid?
(e.g.,weekly, monthly, etc.)?
Name: From: $
Mailing Address: To:
Street:
City:
State: ZIP Code:
e) Did you work full-time or part-time? F/T P/T f) How many hours did you work per week?
g) Is this employer a school employer or a public or nonprot employer where you performed school-related work? Yes No
If yes, provide phone number: – –
20. During the past 18 months did you work for any other
employers not listed in question 19?
20 Yes No
If yes, list the employer information for questions 19 a-g on a separate sheet of
paper. Attach the additional sheet of paper to this application.
21. If the EDD nds that you do not have sufcient wages
in the Standard Base Period to establish a valid claim,
do you want to attempt to establish a claim using the
Alternate Base Period?
For additional information about the Standard Base
Period and the Alternate Base Period, visit the EDD
website www.edd.ca.gov.
21 Yes No
22. During the past 18 months, which employer did you
work for the longest?
a) What type of business was operated by the
employer? (Please be specic. For example,
restaurant, dry cleaning, construction, book store.)
b) How long did you work for that employer?
c) What type of work did you do for that employer?
22. Employer name:
a) Type of business:
b) Years: Months:
c)
23. What is your usual occupation? 23.
24. Is your usual work seasonal?
If yes, answer questions a-c:
a) When does the season usually begin?
b) When does the season usually end?
c) What other work-related skills do you have?
24. Yes No
If yes, answer questions a-c:
a) (mm/dd/yyyy)
b) (mm/dd/yyyy)
c)
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UNEMPLOYMENT INSURANCE APPLICATION
Social Security number: – –
Please provide information about 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.
If you worked for a temporary agency, a labor contractor, an agent for actors or actresses, or an employer where wages are
reported under a corporate name, your wages may have been reported under that employer name. If you worked for In-Home
Supportive Services (IHSS), the welfare recipient for whom you provided the in-home supportive service is your employer, not
the county. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer.
Reminder: To le a claim, individuals must be out of work or working less than full time. You must provide information about the
last employer you worked for as an employee. Do not include self-employment unless you have elective coverage.
25. What is the last date you actually worked for your very
last employer?
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.
b) What is the complete name of your very last
employer?
c) What is the mailing address of your very last
employer?
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?
e) What is the telephone number of your very last
employer at their physical address?
f) What is the name of your immediate supervisor?
g) Briey 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.
25. (mm/dd/yyyy)
a) $
b) Name:
c) Mailing address:
Street:
City:
State: ZIP Code:
d) Yes No
Physical address:
Street:
City:
State: ZIP Code:
e) – –
f)
g) Reason:
26. Are you (directly or indirectly) out of work with any
employer (last employer or any employer in the last
18 months) due to a trade dispute, such as a strike or
a lockout?
26. Yes No
If yes and a union was/is involved, answer
questions a-b:
If yes and a union was not/is not involved, answer questions c-e:
a) What is the name and telephone number of the
union?
Name:
Phone: – –
b) Are you going to receive strike benets?
Yes No
c) How many employees left work?
d) Was there a spokesperson for the employees? Yes No
e) If yes, what is his/her name and telephone number?
Name:
Phone: – –
1101I05
DE 1101ID Rev. 5 (5-21) (INTERNET) Page 6 of 12
UNEMPLOYMENT INSURANCE APPLICATION
Social Security number: – –
27. Are you currently working for or do you expect to work
for any school or educational institution or a public or
nonprot employer performing school-related work?
If yes, answer questions a-e:
a) Provide the following information for the school or
educational institution(s) or the public or nonprot
employer(s).
b) Are you a substitute teacher for Los Angeles
Unied School District (LAUSD)?
c) Are you currently in a recess period or off track?
d) Do you have reasonable assurance to return to
work after the recess period or the off track period
with any school or educational institution?
e) What is the beginning date of your next recess or
the next off track period?
27. Yes No
If yes, answer questions a-e:
a) Name:
Mailing Address:
Street:
City:
State: ZIP Code:
Phone: – –
Name:
Mailing Address:
Street:
City:
State: ZIP Code:
Phone: – –
b) Yes No
c) Yes No
d) Yes No
If yes, when? (mm/dd/yyyy)
e) (mm/dd/yyyy)
28. Do you expect to return to work for any former
employer?
28. Yes No
29. Do you have a date to start work with any employer?
If yes, answer question a:
a) What date will you start work?
29. Yes No
If yes, answer question a:
a) (mm/dd/yyyy)
30. Are you a member of a union or non-union trade
association?
If yes, answer questions a-f:
a) What is the name of your union or non-union
organization?
b) What is your union local number?
c) What is the telephone number of your union or
non-union trade association?
d) Does your union or non-union trade association
nd work for you?
e) Does your union or non-union trade association
control your hiring?
f) Are you registered with your union or non-union
trade association as out of work?
30. Yes No
If yes, answer questions a-f:
a)
b) (Enter zero “0” for non-union trade association.)
c) – –
d) Yes No
e) Yes No
f) Yes No
1101I06
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UNEMPLOYMENT INSURANCE APPLICATION
Social Security number: – –
31. Are you currently attending, or do you plan on
attending school or training?
If yes, answer question a-g:
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?
e) What are the days and hours you are attending, or
plan to attend, school?
f) Is your school or training program authorized or
funded by one of the programs listed in section f?
NOTE: If you are in a State Approved Apprenticeship
training, you must mail your training completion
certicate with your Continued Claim Form,
DE 4581, for the week(s) of training.
g) If you had a job, or were offered a job in your
usual occupation, would the days and hours you
attend school prevent you from working full time?
31. Yes No
If yes, answer questions a-g:
a) (mm/dd/yyyy)
b) (mm/dd/yyyy)
c)
d) Phone: – –
e) Days and hours:
f) Yes No
If yes, check only one box.
Workforce Investment Act (WIA)
Employment Training Panel (ETP)
Trade Adjustment Assistance (TAA)
California Work Opportunity and Responsibility to Kids
(CalWORKS)
State Approved Apprenticeship
Union or Non-union Journey Level
None of the above
g) Yes No
32. 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.
32. Yes No
a) Explanation:
33. 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.
33. Yes No
a) Explanation:
34. 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.)
34. Yes No
35. Are you now, or have you been in the last 18 months
an ofcer of a corporation or union or the sole or major
stockholder of a corporation?
a) If yes, include name of organization and your title
or position.
35. Yes No
a) Name of Organization:
Title/Position:
36. Did you serve as an elected public ofcial or
Governor-exempt appointee in the last 18 months?
36. Yes No
1101I07
DE 1101ID Rev. 5 (5-21) (INTERNET) Page 8 of 12
UNEMPLOYMENT INSURANCE APPLICATION
Social Security number: – –
37. Are you currently receiving a pension?
If yes, answer question a:
a) Are you currently receiving more than one pension?
If yes, proceed to question 38.
If no, answer questions b-f:
b) What is the name of the pension provider?
c) Is the pension based on another person’s work or
wages?
d) Is the pension a union pension or a pension
funded by more than one employer?
e) What is the name of the employer(s) paying into
the pension?
f) Did you work for that employer in the last
18 months?
37. Yes No
If yes, answer question a:
a) Yes No
If yes, proceed to question 38.
If no, answer questions b-f:
b)
c) Yes No
d) Yes No
e)
f) Yes No
38. Will you receive any additional pension(s) in the next
12 months?
If yes, answer questions a-b:
a) What is the name of the pension provider(s)?
b) When will you receive the pension(s)?
38. Yes No
If yes, answer questions a-b:
a)
b) (mm/dd/yyyy)
(mm/dd/yyyy)
39. Are you receiving, or do you expect to receive,
Workers’ Compensation?
If yes, answer questions a-d:
a) Who is the insurance carrier?
b) What is the insurance carrier’s telephone number?
c) What is the case number, if known?
d) What are the dates of your claim, if known?
39. Yes No
If yes, answer questions a-d:
a)
b) Phone: – –
c)
d) From: (mm/dd/yyyy)
To: (mm/dd/yyyy)
40. Have you received or do you expect to receive, any payments from your last employer, other than your Yes No
regular salary? (Example: holiday pay, vacation pay, severance pay, in-lieu-of-notice pay, etc.)
If yes, provide the information in sections A-D. If you received severance pay as a lump sum, complete sections A-C (in section C, report
the date the lump-sum payment was made).
A.
TYPE OF PAYMENT
(Example: vacation pay)
B.
AMOUNT OF PAYMENT
(Example: $600)
C.
PAID FROM
(Date: mm/dd/yyyy)
D.
PAID TO
(Date: mm/dd/yyyy)
1101I08
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UNEMPLOYMENT INSURANCE APPLICATION
Social Security number: – –
41. Are you a U. S. Citizen or National?
If no, answer question a:
a) Are you registered with the United States
Citizenship and Immigration Services (USCIS,
formerly INS) and authorized to work in the
United States?
b) Were you legally entitled to work in the United
States for the last 19 months?
41. Yes No
If no, answer question a:
a) Yes No
b) Yes No
IMPORTANT: If you answered “yes” to question “a” above, you must select one of the USCIS documents listed in 41A through 41H
below and provide the applicable document information.
41A. Permanent Resident Card (I-551)
1) Alien Registration Number (A#)
2) Permanent Resident Card Number (CARD#)
NOTE: The CARD# is on the back of the card, next to
your photo, under the DOB and the EXP date.
3) Expiration Date (EXP)
41A. Permanent Resident Card (I-551)
1) A#
The Alien Registration Number must be 7 to 9 digits long. Enter numeric
digits only.
2)
The CARD# must be 13 characters long. Enter 3 alphabetic characters
followed by 10 numeric digits. If your current card was issued to you
before December 1997, leave this blank.
3) (mm/dd/yyyy)
41B. Employment Authorization Card (I-766)
1) Alien Registration Number (A#)
2) Expiration Date
41B. Employment Authorization Card (I-766)
1) A#
The Alien Registration Number must be 7 to 9 digits long. Enter numeric
digits only.
2) (mm/dd/yyyy)
41C. Refugee Travel Document (I-571)
1) Alien Registration Number (A#)
2) Expiration Date
41C. Refugee Travel Document (I-571)
1) A#
The Alien Registration Number must be 7 to 9 digits long. Enter numeric
digits only.
2) (mm/dd/yyyy)
1101I09
DE 1101ID Rev. 5 (5-21) (INTERNET) Page 10 of 12
UNEMPLOYMENT INSURANCE APPLICATION
Social Security number: – –
41D. Arrival/Departure Record (I-94)
1) Arrival/Departure Number
2) Expiration Date
41D. Arrival/Departure Record (I-94)
1)
The Arrival/Departure Number must be 11 digits long. Enter numeric
digits only.
2) (mm/dd/yyyy)
41E. Re-entry Permit (I-327)
1) Alien Registration Number (A#)
2) Expiration Date
41E. Re-entry Permit (I-327)
1) A#
The Alien Registration Number must be 7 to 9 digits long. Enter numeric
digits only.
2) (mm/dd/yyyy)
41F. Unexpired Foreign Passport
1) Arrival/Departure Number
2) Passport Number
3) Visa Number
4) Expiration Date
41F. Unexpired Foreign Passport
1)
The Arrival/Departure Number must be 11 digits long. Enter numeric
digits only.
2)
The passport number must be 6 to 12 alphanumeric characters. It is
usually found on the top right corner of the document.
3)
The Visa Number must be 8 numeric digits.
4) (mm/dd/yyyy)
41G. Arrival/Departure Record (I94) in Unexpired
Foreign Passport
1) Arrival/Departure Number
2) Passport Number
3) Visa Number
4) Expiration Date
41G. Arrival/Departure Record (I94) in Unexpired Foreign Passport
1)
The Arrival/Departure Number must be 11 digits long. Enter numeric
digits only.
2)
The passport number must be 6 to 12 alphanumeric characters. It is
usually found on the top right corner of the document.
3)
The Visa Number must be 8 numeric digits.
4) (mm/dd/yyyy)
41H. Other Document (not listed in Section A to G)
1) Alien Registration Number (A#)
2) Arrival/Departure Number
3) Expiration Date
4) Document Description
41H. Other Document (not listed in Section A to G)
1) A#
The Alien Registration Number must be 7 to 9 digits long. Enter numeric
digits only.
2)
The Arrival/Departure Number must be 11 digits long. Enter numeric
digits only.
3) (mm/dd/yyyy)
4) Document Description:
1101I10
DE 1101ID Rev. 5 (5-21) (INTERNET) Page 11 of 12
UNEMPLOYMENT INSURANCE APPLICATION
Social Security number: – –
SUPPLEMENTAL FORM FOR DISASTER UNEMPLOYMENT ASSISTANCE (DUA) – ATTACHMENT D
Please complete the following if you are unemployed or partially unemployed due to a disaster as you may be eligible for
DUA benets:
1. Are you unemployed as a direct result of a recent
disaster in California, such as an earthquake, ood,
mudslide, wildre, etc.?
If yes:
a) Identify the type of disaster.
b) At the time of the disaster, in which county did you
reside?
c) At the time of the disaster, in which county did you
work?
d) At the time of the disaster, was your
unemployment caused by your need to travel
through a disaster area?
If yes:
Identify the disaster county or counties that
prevent travel to your job.
e) Check the following that best applies to you:
f) If you selected item e1 or e3 above, how many
hours did you work prior to the disaster?
g) If you selected e3 or e4 above briey describe
how the disaster affected your ability to continue
or begin your self-employment.
h) What is the physical address of your business?
1. Yes No
If yes, answer questions a-d:
a)
b)
c)
d) Yes No
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 self-employment, but could
not because of the disaster.
5) An individual who became head of household as a result of the
disaster.
f)
g)
h) Street:
City:
State: ZIP Code:
1101I11
DE 1101ID Rev. 5 (5-21) (INTERNET) Page 12 of 12
UNEMPLOYMENT INSURANCE APPLICATION
Social Security number: – –
DO NOT MAIL OR FAX THIS PAGE
SUBMITTING YOUR APPLICATION
Be sure to review your application thoroughly for completeness. An incomplete application may delay or prevent the ling of your
claim, or cause benets to be denied.
Submit your completed application including any applicable attachment(s) by mail or fax:
By MAIL to the following address: EDD
PO Box 989738
West Sacramento, CA 95798-9738
NOTE: Extra postage is required.
By FAX to the following telephone number: 1-866-215-9159
Once you submit your application, allow 10 days for processing of your claim. You will receive Unemployment Insurance
(UI) claim materials by mail. If you have not received any UI claim materials after 10 days from the date you submitted your
application, call one of the following toll-free telephone numbers:
English 1-800-300-5616 Spanish 1-800-326-8937 Mandarin 1-866-303-0706
TTY (Non Voice) 1-800-815-9387 Cantonese 1-800-547-3506 Vietnamese 1-800-547-2058
Date Submitted: by Mail or Fax
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UNEMPLOYMENT INSURANCE APPLICATION (California)

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Completed 1 April 2022

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