Form Cli001f - Unemployment Insurance Claim Application Page 4
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4Employment History
List where you have worked during the past 18 months. (Start with your most recent job.)
If you worked for a Temporary Agency, provide the name, address, and phone # of the Agency.
*Employer Name:
*Address:
*City:
*State:
*Zip
*Company Phone #:
(
)
-
*For this period of employment, what date did you start?
/
/
*Last date worked:
/
/
Total # of days worked:
*In what state(s) was your work performed?
/
/
/
Laid-Off (Lack of Work)
Discharged (Fired)
*Why are you no longer working for this employer? (check one)
Quit
Strike / Labor Dispute (Ask for LD Questionnaire)
Still Working (Part Time)
Military Discharge
If you worked for a Temporary Agency provide the name of the employer you worked for or were assigned to.
Employer Name:
*What was your most recent job title:
If you have other employers in the past 18 months, list below. If none, skip to Claimant Certification.
(Office Use Only) UI Acct#:
*How many weeks OWBA:
LEU
BCE
LAG
*Employer Name:
*Address:
*City:
*State:
*Zip
*Company Phone #:
(
)
-
/
/
*Last date worked:
/
/
*For this period of employment, what date did you start?
Total # of days worked:
*In what state(s) was your work performed?
/
/
/
*Why are you no longer working for this employer? (check one)
Laid-Off (Lack of Work)
Discharged (Fired)
Quit
Strike / Labor Dispute (Ask for LD Questionnaire)
Still Working (Part Time)
Military Discharge
If you worked for a Temporary Agency provide the name of the employer you worked for or were assigned to.
Employer Name:
(Office Use Only) UI Acct#:
*How many weeks OWBA:
LEU
BCE
LAG
If you need to list more employers, request the Work History Form.
Claimant Certification - Please Read Carefully
I hereby file a claim for unemployment insurance benefits. I certify that the information for my benefit claim, including the status of my
dependents, is true and correct to the best of my knowledge and belief. I am aware that the law prescribes penalties of fine and imprisonment for
making false statements to obtain benefits, including dependent allowance. I understand that the information submitted by me may be verified
through matching programs and will be used by other Federal, State, or Local Agencies and that information submitted by me to these agencies
will be used by IDES in determining my eligibility and amount of unemployment benefits. I also understand that, pursuant to Section 1900 of the
Unemployment Insurance Act, any information that I provide to the Department of Employment Security in connection with the claim may be
shared with my former employers or their representatives.
I understand that, unless I am exempt, registration for work with the Illinois Employment Service is a requirement to be eligible for Unemployment
Insurance Benefits under Section 500A of the Illinois Unemployment Insurance Act; unemployment insurance benefits will not be paid until I
complete my registration; and registration can be completed by visiting
/
/
*CLAIMANT SIGNATURE:
*DATE:
CLI001F
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