Insurance Security

Location:

Fresno, CA, 93703

Posted:

August 17, 2010

Contact this candidate

Resume:

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number: __ __ __ - __ __ - __ __ __ __

FILING INSTRUCTIONS

Complete this application including any applicable attachment(s). Print or type the information. Use blue or

black ink only.

Answer all questions on each page. Review your application thoroughly for completeness. An incomplete

application may delay or prevent the filing of your claim, or cause benefits to be denied. If the Department

needs to verify any of the information you provide while filing a claim, you will receive additional forms by

mail and will be asked to provide additional information and/or documentation.

APPLICATION QUESTIONS

The answers you give to the questions on this application must be true and correct. You may be subject to

penalties if you make a false statement or withhold information.

1. ***-**-****

1. What is your Social Security Number as given to you by

the Social Security Administration?

a) If EDD assigned you an EDD Client Number (ECN),

please provide the ECN here. (An ECN is a 9digit

number beginning with 999.)

2. List any other Social Security Numbers you have used.

3. Last Egetian

3. What is your full name?

First Bryan

Middle Initial A

4. Is this the name that appears on your Social Security 4. Yes No

card?

a) Last

a) If no, provide the name that appears on your Social

Security card.

First

Middle Initial

5. List any other names you have used.

6. 08/12/1985

6. What is your birth date? (mm/dd/yyyy)

7. What is your gender? 7. Male Female

8. Would you prefer your written material in English or 8. English Spanish

Spanish?

a) What is your preferred spoken language?

9. Have you filed a California Unemployment Insurance or 9. Yes No

a Disability Insurance claim in the last two years?

Unemployment Claim Date(s) (mm/dd/yyyy)

a) If yes, please list for each type of claim, the most

recent date(s) of when the claim(s) was filed.

Disability Claim Date(s) (mm/dd/yyyy)

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number ***-**-****

10. Do you have a Driver’s License issued to you by a state/entity?

a) If yes, provide the name of the issuing state/entity and your Driver’s License number.

If no, answer questions b-d:

b) Do you have an Identification Card issued to you by a state/entity?

c) If yes, provide the name of the issuing state/entity and your Identification Card number.

d) How do you look for work and, if you have work, how do you get to work?

10. Yes No

a) Name of issuing state/entity: California

Driver’s License Number: D3313006

If no, answer questions b-d:

b) Yes No

c) Name of issuing state/entity:

Identification Card Number:

d) Please Explain:

11. What is your telephone number?

a) If you are deaf, hard of hearing, or have a speech disability and use TTY or California Relay to communicate, check the

appropriate box.

11. 559-***-****

a) TTY (Non Voice) California Relay Service

12. What is your mailing address?

(Include your city, state, and ZIP code)

12. Street: 2326 E. Michigan Ave

City: Fresno

State: Ca ZIP Code: 93703

13. Is your residence address the same as your mailing address?

a) If no, enter your residence address. (Include your city, state, ZIP code and apartment number.) A residence address

cannot be a P.O. Box. Please provide a street address.

13. Yes No

a) Street: Apt.

City:

State: ZIP Code:

14. If you do not live in California, what is the name of the County in which you live?

UNEMPLOYMENT INSURANCE APPLICATION

14.

15. What is the highest grade of school you have completed? Check only one box.

Did not complete High School High School Diploma or GED Some college or vocational school

Associate of Arts Bachelor of Arts or Science Masters or Doctorate

16. Are you a Military Veteran?

16. Yes No

Social Security Number: ***-**-****

17. Provide your employment and wages information for the past 18 months. If you worked for a temporary agency, a labor

contractor, an agent for actors or actresses, or an employer where wages are reported under a corporate name, your wages may

have been reported under that employer name. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your

employer.

a) Name(s) of all employers you worked for in the last 18 months.

b) Period of employment (Dates Worked).

c) Total Wages earned for each employer in the last 18 months.

d) How you were paid (specify hourly, weekly, monthly, annually, commission, or at piece rate).

e) Check the appropriate “Yes/No” box if the employer is (or is not) a school or educational institution.

NOTE: It is very important that you report the employer name(s), period of employment and wages correctly. Failure to provide

complete information will result in your benefits being delayed or denied.

a) Employer Name b) Dates Worked c) Total Earnings d) How were you

paid?

United States Coast Guard From: 03/26/2007 Direct Deposit

To: 05/28/2010

If yes, provide phone number

e) Is this employer a school employer? Yes No

a) Employer Name b) Dates Worked c) Total Earnings d) How were you

paid?

From:

To:

If yes, provide phone number

e) Is this employer a school employer? Yes No

a) Employer Name b) Dates Worked c) Total Earnings d) How were you

paid?

From:

To:

If yes, provide phone number

e) Is this employer a school employer? Yes No

a) Employer Name b) Dates Worked c) Total Earnings d) How were you

paid?

From:

To:

If yes, provide phone number

e) Is this employer a school employer? Yes No

a) Employer Name b) Dates Worked c) Total Earnings d) How were you

paid?

From:

To:

If yes, provide phone number

e) Is this employer a school employer? Yes No

a) Employer Name b) Dates Worked c) Total Earnings d) How were you

paid?

From:

To:

If yes, provide phone number

e) Is this employer a school employer? Yes No

18. During the past 18 months did you work for any other 18. Yes No

employers not listed in question 17?

If yes, list the employer name, dates worked, total

earnings, and how you were paid on a separate sheet of

paper. Attach the additional sheet of paper to this

application.

Social Security Number: ***-**-****

19. Employer name: United States Coast Guard

19. Which employer in question 17 did you work for the

longest?

a) Type of business:

a) What type of business was operated by the

Military

employer? (Please be specific. For example,

restaurant, dry cleaning, construction, book store.)

b) Years 3 Months 0

b) How long did you work for that employer?

c) Deisel Mechanic

c) What type of work did you do for that employer?

20. Sales

20. What is your usual occupation?

21. Yes No

21. Is your usual work seasonal?

If yes, answer questions a-c:

a) When does the season usually begin?

b) When does the season usually end?

c) What other work related skills do you have?

Please provide information on your very last employer. This is the employer you last worked for regardless of the length of time you

worked at that job, the type of work you did for that employer or whether or not you have been paid.

Reminder: To file a claim, individuals must be out of work or working less than full time. You must provide information on the last

employer you worked for as an employee. Do not include self-employment unless you have elective coverage.

22. 03/26/2007

22. What is the last date you actually worked for your very (mm/dd/yyyy)

last employer?

a) $500.00

a) What are your gross wages for your last week of

work? For unemployment insurance purposes, a

week begins on Sunday and ends the following

Saturday.

b) Name: United States Coast Guard

b) What is the complete name of your very last

employer?

c) Mailing address:

c) What is the mailing address of your very last

employer? Street: 1 U.S. Coast Guard Training Center

City: Yorktown

State: Va ZIP Code: 23690

d) Yes No

d) Is the physical address of your very last employer

the same as their mailing address? (A physical

address cannot be a P.O. Box. Please provide a

street address.)

Physical address:

If no, what is the physical address of your very last

employer?

Street:

City:

State: ZIP Code:

e) What is the telephone number of your very last e)

employer at their physical address?

f) What is the name of your immediate supervisor? f)

g) Briefly explain in your own words the reason you are

g) Reason:

no longer working for your very last employer,

within the space provided. Please do not include

any attachments.

Social Security Number: ***-**-****

23. Are you (directly or indirectly) out of work with any employer (last employer or any employer in the Yes No

last 18 months) due to a trade dispute, such as a strike or a lockout?

If yes and a union was/is involved, answer questions a-b: If yes and a union was not/is not involved, answer questions c-e:

c) How many employees left work?

a) What is the name and telephone number of the union?

Name: d) Was there a spokesperson for the employees? Yes No

Phone:

e) If yes, what is his/her name and telephone number?

Name:

b) Are you going to receive strike benefits? Yes

Phone:

24. Are you currently working for or do you expect to work for 24. Yes No

any school or educational institution or perform school-

related work?

If yes, answer questions a-e:

a) Name:

a) Provide the following information for the school or

educational institution(s). Mailing Address:

Street:

City:

State: ZIP Code:

Phone:

a) Name:

Mailing Address:

Street:

City:

State: ZIP Code:

Phone:

b) Are you a substitute teacher for Los Angeles b) Yes No

Unified School District (LAUSD)?

If yes, answer question 1) If yes, answer question 1)

1) 1) Yes No

Have you restricted your availability to

work with LAUSD?

Dates From: (mm/dd/yyyy)

If yes, provide the following dates you

To: (mm/dd/yyyy)

restricted your availability and the reason

why your availability is restricted.

Reason:

c) Yes No

c) Are you currently in a recess period or off track?

d) Yes No

If yes, when? (mm/dd/yyyy)

d) Do you have reasonable assurance to return to

work after the recess period or the off track period

e) (mm/dd/yyyy)

with any school or educational institution?

e) What is the beginning date of your next recess or

the next off track period?

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number: ***-**-****

25. Do you expect to return to work for any former 25. Yes No

employer?

26. Yes No

26. Do you have a date to start work with any employer?

If yes, answer question a:

a) (mm/dd/yyyy)

a) What date will you start work?

27. Are you a member of a union? 27. Yes No

If yes, answer questions a-e: If yes, answer questions a-e:

a) What is your union name and local number?

b) Are you in good standing with your union? b) Yes No

c) Does your union look for work for you? c) Yes No

d) Does your union control your hiring? d) Yes No

e) Are you registered with your union as out of work? e) Yes No

28. Yes No

28. Are you currently attending, or do you plan on attending

school or training?

If yes, answer questions a-e:

If yes, answer question a-e:

a) (mm/dd/yyyy)

a) What is the starting date of the school or training?

b) What is the ending date of the current session? (mm/dd/yyyy)

c) What is the name of the school?

d) What is the telephone number of the school?

e) What are the days and hours you are attending, or e) Days and hours:

plan to attend, school?

NOTE: If you completed apprenticeship training,

use the space provided above to report the

information. Be sure to mail your training

certificate with your Continued Claim Form,

DE 4581, for the week(s) of training.

29. Yes No

29. Are you available for immediate full-time work in your

usual occupation?

a) Explanation:

a) If no, please explain why you are not available for

full-time work.

30. Yes No

30. Are you available for immediate part-time work in your

usual occupation?

a) Explanation:

a) If no, please explain why you are not available for

part-time work.

31. Are you currently self-employed, or do you plan to 31. Yes No

become self-employed? (Self-employment means you

have your own business or work as an independent

contractor.)

Social Security Number: ***-**-****

32. Are you now, or have you been in the last 18 months an 32. Yes No

officer of a corporation or union or the sole or major

stockholder of a corporation?

If yes, answer question a:

a) Include name of organization and your title or

position.

33. Are you currently receiving a pension? 33. Yes No

If yes, answer question a: If yes, answer question a:

a) Are you currently receiving more than one pension? a) Yes No

If yes, proceed to question 35. If yes, proceed to question 35.

If no, answer questions b-f: If no, answer questions b-f:

b) What is the name of the pension provider?

c) Is the pension based on another person’s work or c) Yes No

wages?

d) Is the pension a union pension or a pension funded d) Yes No

by more than one employer?

e) What is the name of the employer(s) paying into the

pension?

f) Did you work for that employer in the last 18 f) Yes No

months?

34. Will you receive any additional pension(s) in the next 34. Yes No

twelve months?

If yes, answer questions a-b:

a) What is the name of the pension provider(s)?

b) (mm/dd/yyyy)

b) When will you receive the pension(s)?

(mm/dd/yyyy)

35. Are you receiving, or do you expect to receive, 35. Yes No

Workers’ Compensation?

If yes, answer questions a-d: If yes, answer questions a-d:

a) Who is the insurance carrier?

b) What is the insurance carrier’s telephone number?

c) What is the case number, if known?

d) What are the dates of your claim, if known? d) From: (mm/dd/yyyy)

To: (mm/dd/yyyy)

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number: ***-**-****

36. Have you received or do you expect to receive, any payments from your last employer, other than your Yes No

regular salary? (Example: holiday pay, vacation pay, severance pay, in-lieu-of-notice pay, etc.)

If yes, please provide the information requested in sections A-D.

A. B. C. D.

TYPE OF PAYMENT AMOUNT OF PAID FROM PAID TO

(Example: vacation pay) PAYMENT (Date: mm/dd/yyyy) (Date: mm/dd/yyyy)

(Example: $600)

37. Are you a U. S. citizen or national? 37. Yes No

If no, answer question a: If no, answer question a:

a) Are you registered with the Bureau of Citizenship a) Yes No

and Immigration Services (BCIS, formerly INS) and

authorized to work in the United States?

If you are registered with BCIS, answer questions b-e: If yes, answer questions b-e:

b) What is your Alien Registration Number?

c) What is the expiration date of your work (mm/dd/yyyy)

authorization?

d) Were you legally entitled to work in the United States

d) Yes No

for the last 19 months?

e) What is the title and number of your BCIS

e) Check one of the following:

document?

Alien Registration Receipt Card (I-151)

Resident Alien Card (I-551)

Permanent Resident Card (I-551)

Employment Authorization Card (I-766)

Employment Authorization Card (I-688A)

Temporary Resident Card (I-688)

Employment Authorized (I-688B)

Arrival/Departure Record (I-94)

Stamp on Visa

(Stamp states: “Processed for I-551 Temporary Evidence

of Lawful Admission of Permanent Residence valid until

MMDDYYYY, Employment Authorized.”)

38. What race or ethnic group do you identify with?1. Army #019

EDD Navy

P.O. Box 1041

Coast Guard

Atwood, CA 92811-1041

NOTE: Extra postage is required.

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UNEMPLOYMENT INSURANCE APPLICATION

39. Do you have a disability? (A disability is a physical or

mental impairment that substantially limits one or more

life activities, such as caring for oneself, performing

manual tasks, walking, seeing, hearing, speaking,

breathing, learning, or working.)

Social Security Number: 548-87-

8165

Security

Number:

8165

SUPPLEMENTAL FORM FOR EX-

SERVICEMEMBERS – ATTACHMENT A

Please refer to your Certificate of Release or

Discharge from Active Duty, DD Form 214, to

complete this form (if you have a NOAA Form

56-16, it can be used in place of the

DD Form 214).

1. What is your branch of service?

2. 2. Yes No

Were you in the Reserves?

3. Did you complete a first full-term of 3. Yes No

service?

4. What is the Social Security Number on 4. ***-**-****

your DD Form 214? (Section 3)

5. What is your Pay Grade? 5. E-4

(DD Form 214, Section 4b)

6. What is your Entry Date? 6. 0326/20/07

(DD Form 214, Section 12a)

7. What is your Separation Date? 7. 0528/20/07

(DD Form 214, Section 12b)

8. What is your Net Active Service? 8. 02/03/02

(DD Form 214, Section 12c)

9. 9.

What is your

Character of Service?

(DD Form 214, Section

24)

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UNEMPLOYMENT INSURANCE APPLICATION

10. What is the Narrative Reason for 10. Disability, Severance Pay

Separation? (DD Form 214,

Section 28)

11. What is your DD 214 Member number? 11. -7

(Located on lower right corner of form)

12. Report all dates of time 12.

lost during this period.

(DD Form 214, Section

29)

SUPPLEMENTAL FORM FOR DISASTER

UNEMPLOYMENT ASSISTANCE (DUA) –

ATTACHMENT D

Please complete the following if you are unemployed or

partially unemployed due to a disaster as you may be eligible

for DUA benefits:

1. Are you unemployed as a direct result of a recent disaster

in California, such as an earthquake, flood, mudslide,

wildfire, etc?

If yes:

a) Identify the type of disaster.

b) At the time of the disaster, in which county did you

reside?

c) At the time of the disaster, in which county did you

work?

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UNEMPLOYMENT INSURANCE APPLICATION

d) At the time of the disaster, was your unemployment

caused by your need to travel through a disaster

area?

If yes:

Identify the disaster county or counties that prevent

travel to your job.

e) Check the following that best applies to you:

f) If you selected item e1 or e3 above, how many hours

did you work prior to the disaster?

g) If you selected e3 or e4 above briefly describe how

the disaster affected your ability to continue or begin

your self-employment.

h) What is the physical address of your business?

DO NOT MAIL OR FAX THIS

PAGE

SUBMITTING YOUR APPLICATION

Be sure to review your application thoroughly for

completeness. An incomplete application may

delay or prevent the filing of your claim, or cause

benefits to be denied.

Submit your completed application including

any applicable attachment(s) by mail or fax:

By MAIL to the following address:

By FAX to the following telephone number: 1-866-***-****

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UNEMPLOYMENT INSURANCE APPLICATION

Once you submit your application, allow ten days for processing of your claim. You will receive Unemployment Insurance

(UI) claim materials by mail. If you have not received any UI claim materials after ten days from the date you submitted

your application, call one of the following toll-free telephone numbers:

English 1-800-***-**** Spanish 1-800-***-**** Mandarin 1-866-***-****

TTY (Non Voice) 1-800-***-**** Cantonese 1-800-***-**** Vietnamese 1-800-***-****

Date Submitted: 07/30/2010 by Mail or Fax

KEEP THIS PAGE FOR YOUR RECORDS

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Contact this candidate