When an individual files for unemployment insurance benefits in the State of Washington, employers find themselves navigating the complexities of the Employment Security Department's procedures, particularly through the EMS 5361 form. This form, titled "Notice To Employer - Claimant's Separation Statement," serves as a critical communication bridge between employers and the Employment Security Department, ensuring that the claim for benefits is warranted and accurate. Designed to capture the circumstances surrounding an employee's departure from work, it seeks an employer's corroboration or contestation on the reasons provided by the claimant, such as "lack of work" or "reduced hours due to lack of work." Employers are urged to provide additional details if the separation reason diverges from these, thus allowing a thorough evaluation by the department. Detailed sections of the form request information about the claimant’s job title, separation conditions, and any severance details like vacation pay or pay in lieu of notice. Furthermore, it delves into specifics should the employer assert that the separation was due to resignation, discharge for cause, or other conditions that may influence the claimant's eligibility for unemployment benefits. By also addressing the possibility of standby arrangements, where a return to work date is anticipated, the form encapsulates scenarios to ensure all parties are fairly represented. Should employers overlook the directive to respond by a specified deadline, the department may proceed to adjudicate the claim with the evidence at hand, impacting the employer's experience rating and potentially the decision on the claimant’s eligibility for benefits. Thus, this document underscores the participatory role employers play in the adjudication of unemployment claims, embedding a system of checks and balances within the unemployment insurance framework.
| Question | Answer |
|---|---|
| Form Name | Form Ems 5361 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | xxxx, ems 5361, claimant, SSN |
State of Washington
Notice To Employer - Claimant’s Separation Statement
IMPORTANT: The following claimant has filed a claim for unemployment insurance benefits and has listed you as one of the last employers. Please review to prevent improper payments.
If the claimant’s statement below says “lack of work” or “reduced hours due to lack of work” and you agree, you can disregard this statement. If the separation is anything other than “lack of work”, please complete and return this form and any other relevant documents by mail or fax. In our decision, we will consider any facts you provide. If we do not hear from you, benefits may be allowed based on available information..
This form must be returned by 7/23/2010. Mailed on: 7/9/2010
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Return Address: |
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BUSINESS NAME |
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Employment Security Department |
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ADDRESS |
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VOICE: |
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P.O. Box 19019 |
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CITY |
STATE AND ZIP |
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Olympia, WA |
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Fax #: |
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TC: 770 |
BYE: 07/09/2011 |
Name: Jane B. Doe |
SSN: 000121234 |
SEQ: 000 |
Date Began: 01/10/2008 |
Last day worked: 07/05/2010 |
Date of Separation: 07/05/2010 |
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Claimant’s separation reason: LACK OF WORK
Employer’s Statement: |
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Began: ____________ Last Worked: ____________ |
Date Separated: ____________ |
Pay Rate: $____________ per (hour/day/etc.) __________ |
Payments: Pay in lieu of notice: $__________ |
Vacation pay: $____________ |
Accrued: $____________ Holiday Pay: $___________ |
Claimant’s Job Title/Occupation: ____________________________________________________________________________________________
Check one and explain if separation is other than lack of work or reduced hours due to lack of work: |
Quit |
Fired |
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Did not meet standards |
Labor Dispute |
Other (explain) _________________________________________________________ |
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I will have more work on ____________________. I would like this person on standby Yes No. If yes, dates: Mo. ____ Day ____ Yr. _____.
(NOTE: Standby can only be granted when the claimant has a definite return to work date that is within four weeks. An employer can request an additional four weeks for a maximum of eight weeks per claim. Claimants on standby are not required to seek work, but are required to accept any suitable work you offer.)
Quit Information:
1.What reason did the claimant give for quitting on the last day? _______________________________________________________________
__________________________________________________________________________________________________________________
2.Did the claimant state he/she quit for one or more of the following reasons (check all that apply):
Quit to accept a new offer of work?
Quit due to illness or disability of: self or family member? If yes, was medical verification provided? Yes or No.
Is the claimant eligible for reinstatement? Yes or No.
Quit to relocate due to spouse/domestic partner’s transfer for: existing job; new job; or military transfer?
Quit due to domestic violence or stalking of self or family member?
Reduction in pay and/or fringe benefits? If yes, by what percentage? ________. Was the reduction: permanent or temporary?
Reduction in hours of work? If yes, by what percentage? ________. Was the reduction: permanent or temporary?
Relocation of work site or modification to his/her shift or schedule? If yes, was the relocation: permanent or temporary?
Alleged safety violations at the work site? If yes, was the violation reported to you? Yes or No
Alleged illegal activities at the work site? If yes, was the problem reported to you? Yes or No
Religious or moral reasons due to a change in customary job duties? If yes, what was the change? ________________________________
Quit to enter an apprenticeship training program?
Other?
Please provide specific details relating to the reason(s) checked (i.e., if change was temporary, until what date, etc.): _____________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
EMS 5361 GUIDE 6/09
(2 of 2)
Name: Jane B. Doe |
SSN: 000121234 |
3.Did the claimant pursue any alternatives to resolve any problems, such as transfer, leave of absence, etc.? Yes or No __________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Discharge Information:
1.What was the final incident that caused the claimant to be discharged? _________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
2.Was the claimant discharged for one or more of the following reasons (check all that apply):
Insubordination?
Repeated inexcusable tardiness?
Dishonesty related to employment?
Repeated and inexcusable absences?
Deliberate acts that are illegal, provoke violence or violation of laws? If yes, what was the act? __________________________________
Violation of a company rule? If yes, what was the rule? _________________________________________________________________
Violations of law while acting within the scope of employment? If yes, what was the law? ______________________________________
Unable to do the job through no fault of his/her own?
Other? ________________________________________________________________________________________________________
Please provide specific details relating to the reason(s) checked. (e.g., dates of tardiness/absences, how many warnings, etc.): ______________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
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3.Do you believe the claimant’s actions were: deliberate or negligent? (explain) _________________________________________________
__________________________________________________________________________________________________________________
4.Could the claimant’s actions have caused a potential harm to your business? Yes or No (explain) __________________________________
__________________________________________________________________________________________________________________
5.If a law was violated, will you file criminal charges? Yes or No. Have charges been filed? Yes or No. Where? ___________________
__________________________________________________________________________________________________________________
Availability: Explain any reason you feel the claimant is not available for work. _____________________________________________________
______________________________________________________________________________________________________________________
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WAC
RELIEF OF BENEFIT CHARGES. If you were also one of the claimant’s base year employers, you may be eligible for relief of charges to your experience rating if the separation from work was (1) a quit not attributed to the employer or (2) a discharge for
Please mark the appropriate box: Claimant quit, not employer’s fault. Claimant was discharged for misconduct.
Name: _________________________________ Title: _____________________ Business Name: ________________________________________
Signature: ________________________________________ ES Ref#: ____________________ Phone: (_______) ___________________________