Employer Information Form Uc-1609
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2EMPLOYER INFORMATION
DEPARTMENT OF LABOR & INDUSTRY
THIS FORM PROVIDES THE EMPLOYEE WITH THE EMPLOYER’S
OFFICE OF UNEMPLOYMENT COMPENSATION BENEFITS POLICY
INFORMATION TO BE USED IF HE/SHE WISHES TO APPLY FOR
UNEMPLOYMENT COMPENSATION BENEFITS.
Employer Name:
PA UC Acct. No.: ___ ___ - ___ ___ ___ ___ ___ ___ (last number is a zero or R or M)
Address (or TPA address):
Telephone:
Fax:
Contact Person:
Title:
Email Address:
Complete the section below only if the employee is expected to return to work at your company.
Employee:
Social Security No.:
Employer Representative Signature
Date
(MM/DD/YYYY)
Expected Date of Recall
FILING AN APPLICATION FOR UNEMPLOYMENT COMPENSATION BENEFITS
Scan below to file
Online: File an online application using our secure website 7 days a week,
an initial claim:
24 hours a day at
Telephone: File an application using our toll-free number 888-313-7284.
(TTY access for the Deaf and Hard of Hearing is available at 888-334-4046.)
Videophone Service: Wednesday from noon to 4 p.m. at 717-704-8474.
Mail or FAX: Mail or FAX a paper application to a UC service center by downloading
the UC paper application from the website: This method of
filing can take longer to process.
It is very important that you provide accurate information about your
employer and the actual reason for your unemployment. Failure to
provide accurate information may delay the processing of your claim
and cause overpayments.
False statements are punishable pursuant to 18 Pa. C.S. §4904, relating to
unsworn falsification to authorities. A person who knowingly makes a false
statement or knowingly withholds information to obtain UC benefits commits
a criminal offense under section 801 of the UC Law, 43 P.S. §871, and may be
subject to a fine, imprisonment, restitution and loss of future benefits.
Please Note: This form does not guarantee your eligibility for UC benefits. After you file your application
for UC benefits, a determination of your eligibility will be made by the Department of Labor & Industry.
Please see back for reemployment information.
UC-1609 REV 05-16 (Page 1)
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