Form K-Ben 3110 - Claimant'S Separation Statement Page 2
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Kansas Department of Labor
Claimant’s Separation Statement
MAIL:
Unemployment Contact Center
K-BEN 3110 Web (Rev. 4-16)
P.O. Box 3539
Topeka, KS 66601-3539
FAX:
(785) 296-3249
EMAIL: KDOLforms@dol.ks.gov
INSTRUCTIONS:
*See important email notice on website.
Information regarding your separation is required before a decision can be made regarding your receipt of unemployment
benefits.
1. This completed form and supporting documents must be received by the Kansas Unemployment Contact Center
at least three (3) days before your scheduled call. Return as directed above. Do not send this form back to the
address on the envelope.
2. You must be available for your scheduled call. If you do not answer your phone when called, a determination will
be made with the information already gathered. Do not call back if you were not available when called. Once a
determination is reached, you will receive it by mail. If your main contact number is a cell phone, please provide an
alternate number. If you do not have a signal or your phone is not working properly, you will not receive a second call.
Failure to be available for your scheduled call may result in a denial of benefits, possible
overpayment and collection of benefits previously received.
If you were DISCHARGED FROM YOUR JOB, include the following information in your statement:
Reason given for discharge.
Name and title of person who discharged you.
Explain fully the final incident/event that caused you to be discharged and on what date this occurred.
If you had been previously warned, give dates and reasons for warnings and whether they were written or verbal.
If warned, list the steps you took to correct the situation.
If you were discharged because you violated a company policy, explain the policy you violated.
If you were discharged for attendance, provide the dates and reasons for your absences and/or tardies.
IMPORTANT: If any of your absences were due to health-related reasons, you will need to submit written documentation from
your health care provider that your absences were necessary. These documents must be submitted to the Contact Center at
least three (3) days before your scheduled call.
If you QUIT YOUR JOB, include the following information in your statement:
Explain in detail the final incident/event that caused you to quit your job.
If you gave advance notice of your intention to quit, provide name and title of person you notified and on what date.
Explain any efforts you made to resolve the problem before you quit. (For example: Did you ask for a transfer, leave of
absence, file a grievance or talk to a supervisor?)
If you quit for medical or health reasons, are currently under the care or recently released from a health care provider,
documentation must be submitted to the Contact Center at least three (3) days before your scheduled call. Be sure
to include in your separation statement whether you were advised to quit your job by your health care provider.
If you quit because of the working conditions, explain in detail the conditions that caused you to quit.
Appeal procedures will be provided with any determination issued.
Begin and continue to file your weekly claims each week while waiting for a decision on your claim.
Keep a copy of this form for your records.
KANSAS UNEMPLOYMENT CONTACT CENTER
Kansas City Area (913) 596-3500 • Topeka Area (785) 575-1460 • Wichita Area (316) 383-9947 • All Other Areas (800) 292-6333
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