Form Cli001f - Unemployment Insurance Claim Application
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4State of Illinois
Department of Employment Security
Unemployment Insurance Claim Application
You must answer all items / sections marked with an asterisk ( * ). (Please Print or Type)
Claimant Information
Enter your full name as it appears on your Social Security card.
Claimant ID:
OR
*SSN:
/
/
*First Name:
MI:
*Last Name:
*Date of Birth: (mm/dd/yyyy)
/
/
Other last name you worked under:
E-Mail Address:
Identification: (Check one and provide information)
Drivers License
Drivers License Number:
State:
State ID
State ID Number:
State:
Other (specify)
Screening
*Are you on break from school, attending school or enrolled in a training program?
Yes
No
*Are you receiving or have you applied for Social Security Benefits?
Yes
No
*Are you receiving or have you applied for Worker’s Compensation?
Yes
No
*Did you receive or will you receive Wages in Lieu of Notice?
Yes
No
*Did you receive or will you receive plant shutdown / vacation pay?
Yes
No
*Are you receiving or have you applied for a pension?
Yes
No
If yes, did you make contributions to your pension fund?
Yes
No
*Are you receiving or have you applied for Railroad Unemployment?
Yes
No
*Did you receive or will you receive Holiday Pay?
Yes
No
*Have you refused any offers of work since your last day of work?
Yes
No
Yes
No
*Have you filed a claim in another state in the past 12 months?
,
If yes, in which city and state:
When did you file?
Yes
No
*Did you work outside the state of Illinois during the last 18 months?
If yes, in which state(s):
*Did you work for an employer who has been certified for Trade Readjustment Allowance, (TRA)?
Yes
No
If yes, ask for TRA Application.
Yes
No
Yes
No
*Do you get work through a Union Local hiring hall?
*If yes, are you a member in good standing?
Union Local:
#:
City:
Yes
No
*Do you have a definite return to work date?
*If yes, provide the date: (mm/dd/yyyy)
/
/
*What is your usual occupation?
(Office Use Only) Occupational Code:
*What were your gross wages during
*What was your last day worked? (mm/dd/yyyy)
$
/
/
the week of your last day worked?
(Office use only) BYB:
DOC:
Rev By:
Entered By:
Filing Method:
In Person
Identity verified using:
Key Identifiers (phone)
Soc. Sec. Card
Phone
Drivers License
Other:
UI
CWC
TRA
EUC
EB
UCX
UCFE
Program:
Other:
Attachments:
Drivers License
State ID
Alien ID
DD-214
EEO
Additional Information:
CLI001F
Page 1 of 4
SN 4227
Rev. 1/2012
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Parent category: Legal