The unemployment claim form.
You will be asked nine questions each week you file a claim.
1. Were you physically able to work full time? Yes or No
a. If no, have you previously reported that you are only available for part-time work because of physical or mental impairment? Yes or No
i. 1f no, select all reasons that apply: Medical Condition / Disability / Other
2. Were you available for full time work? Yes or No
i. If no, select all reasons that apply: Child Care / Transportation / Family Responsibility / Other
3. Did you start school, college or training, which you have not already reported to the Labor Department? Yes or No
4. Did you work in any self-employment not previously reported to the Labor Department? Yes or No
5. Did you perform any work? Yes or No
If you worked last week, Sunday through Saturday you must report any earnings even if you do not get paid until later. Failure to report work and earnings may result in fraud disqualification that will stop your benefits and result in an overpayment to the state of Connecticut.
a. If yes, was the work performed IN self-employment?
6. Do you have a definite date to return to full time employment? Yes or No
a. If yes, please enter the date you will return to full time employment: MM/DD/YYYY
7. Did you refuse any offer of work or rehire? Yes or No
8. Did you receive your first payment from a pension, other than Social Security, that you have not already reported or was there a change in the amount previously reported to the Labor Department? Yes or No
a. If yes, please select the employer from which you are receiving pension.
9. Did you receive dismissal pay(such as severance pay, vacation pay, etc.) or workers compensation, not previously reported to the Labor Department? Yes or No
a. If yes, what kind of dismissal pay did you receive? (Check all if applicable)
i. Wages in Lieu of Notice/Salary Continuance (not including severance pay)
ii. Severance Pay
iii. Paid Time Off (PTO)
iv. Vacation Pay - Other than PTO
v. Supplemental Unemployment Benefit (SUB)
vi. Dismissal pay - Other Payments