Section B - Preparing To File Your Tele-Benefits Claim Page 2

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STATE OF CONNECTICUT - DEPARTMENT OF LABOR
SECTION C -
QUESTIONS
FOLLOW-UP
**You do not have to answer these questions unless directed to do so when answering
**
questions 1 through 20 in Section B.
Question 1. If you worked in a state other than Connecticut in the last 24 months, complete the following:
Information Needed
Employer # 1
Employer # 2
Employer Name
Employer Address
(Complete address)
Dates of Employment
Reason for Separation
Type of Work Performed
Note: If you have additional out of state employment, provide the same information for each employer on another sheet of
paper.
If you filed a claim for unemployment benefits in a state other than Connecticut in the last 24 months, complete the following:
State
Date filed
Question 10. If you are attending school or a training program, complete the following:
Name of school
Days and hours of
attendance
Question 11. If you received Worker’s Compensation or if you were on an approved medical leave, complete the following:
Enter the type of payment. (i.e. If Worker’s Compensation: specific award,
permanent partial, temporary total, temporary partial)
Question 14. If you are receiving primary Social Security benefits, complete the following:
$
/
/
Amount of Social Security
Date began receiving SS

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