Unemployment Commission Form PDF Details

The Unemployment Commission Form is a legal document used to request unemployment benefits. The form must be submitted within certain time limits after the worker becomes unemployed. The purpose of the form is to provide information about the worker's eligibility for unemployment benefits. The Unemployment Commission will use the information on the form to determine whether or not to approve the request for unemployment benefits. There are several sections on the Unemployment Commission Form, including contact information, employment history, wages earned and deductions made, and reason for separation from employment. It is important to complete all sections of the form accurately and honestly. Any false statements may result in denial of unemployment benefits. For more information on how to complete the Unemployment Commission Form, please visit our website.

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QuestionAnswer
Form NameUnemployment Commission Form
Form Length2 pages
Fillable?Yes
Fillable fields130
Avg. time to fill out26 min 34 sec
Other namesnc clm 500 ab, how to file the form ncui 500ab, nc clm 500ab, nc clm 551l form

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NC DEPT. OF COMMERCE – DIVISION OF EMPLOYMENT SECURITY

REQUEST FOR SEPARATION INFORMATION FROM EMPLOYER

The individual named below filed a claim for unemployment insurance benefits and listed you as the last employer. Your reply will be considered when determining the individual’s eligibility if it is received by the due date. Failure to provide a timely, legible and detailed response or failure to attend any appeals hearing related to this claim may result in an increase in your tax rate. You may respond by mail or by fax. If your reply is submitted by fax, please do not return the paper form. Please provide an email address or fax number in case additional information is needed. If the individual is unemployed due to “lack of work” or “inability to perform available work,” the separation will not be examined and your account will be subject to charges for any benefits paid to the claimant.

Return To:

Division of Employment Security

 

 

 

Fax Number: (919) 733-1371

 

 

 

 

Tel Number : (888) 737-0259

 

1.

Date Mailed

2. Response Due Date

3. If the claimant is filing an initial claim and you are also a base

 

 

 

period employer, you will receive, under separate mailing, Form

 

 

 

NCUI 551L Notice of Unemployment Claim, Wages Reported, and

 

 

 

Potential Charges.

 

4.

Claimant Name

 

5. Effective Date of Claim

6. Social Security Number

 

 

 

7. If the claimant did not work for you, check this box.

EAN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Reason why claimant is no

9. If still employed, please check one of the following boxes. Enter the number of hours

longer working:

worked if applicable.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check only one box

 

This claimant was hired full-time (

 

 

) hours and now working reduced (

 

 

) hours.

Temporary Agency (go to Item 14)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This claimant has not separated but was hired part-time and continues to work part-time.

Quit (complete Item 15)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. First Day Worked

 

 

 

11. Last Day Worked (i.e., last

 

12. Rate of Pay

 

 

 

 

 

Discharge (complete Item 16)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

day physically worked)

 

 

 

 

 

 

 

 

 

 

 

 

Inability to perform the work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lack of Work/Laid Off

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

per

 

______

 

Other (complete Item 17)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

M

D

D

Y

Y

Y

Y

M

M

D

 

D

Y

 

Y

Y

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Did claimant receive:

 

 

 

 

 

 

 

 

 

Gross Amount

 

Date Paid

 

 

 

Number of

 

 

 

 

 

 

 

 

 

 

 

Weeks

 

 

Days

 

 

Hours

a. Regular wages for last week worked?

 

Yes

No

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Wages in Lieu of Notice (payment to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

compensate the employee for no notice or

 

Yes

No

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

short notice of layoff)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Vacation Pay (report unused vacation)?

 

Yes

No

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Severance Pay or Separation Bonus?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Compensation for weeks not worked after

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

separation. Each payment impacts the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

claim differently.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Severance Pay?

 

 

 

 

Yes

No

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Separation Bonus?

 

 

 

 

Yes

No

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Other Payment(s)? If Yes, for what

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

reason did you make the payment?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. Company Pension?

 

 

 

 

Yes

No

$

 

 

 

 

 

 

How Paid?

Lump Sum

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(office use only)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(see other side)

NCUI-500AB (Revised 06/30/2013)

Claimant:SSN:DD:

14. COMPLETE THIS SECTION IF YOU ARE A TEMPORARY EMPLOYMENT SERVICES EMPLOYER:

The individual is not separated, is eligible for suitable work assignments, but no suitable work assignments are currently available.

Was claimant offered a new assignment?

Yes

No

If yes, did he/she accept?

Yes

No

If the questions above do not apply to this claimant, please respond to either Item 15 or 16.

Please provide the following information regarding work refused:

Date offered Type of work

Pay Rate: $

 

 

 

Days Hours Distance

Reason

 

HR WK

MO

BI-WK

YR

to site

refused

 

 

 

 

 

 

Go to #17

The following questions refer to the claimant’s last assignment:

Employer name and location:

Claimant’s job:

 

 

 

 

First day worked:

Last day worked:

 

 

 

 

 

 

 

Pay rate: $

 

 

 

 

 

Work hours:

Days worked:

HR WK

MO

BI-WK

YR

 

 

 

 

 

 

 

 

 

 

15.COMPLETE THIS SECTION IF THE CLAIMANT QUIT.

a. What reason did the claimant give for quitting? (If you need more space, continue in Item 17.)

b. Did claimant give prior notification of resignation?

Yes

No If yes, please provide date:

If claimant gave notification was it:

Oral

Written

(Please provide copy)

16.COMPLETE THIS SECTION IF THE CLAIMANT WAS DISCHARGED. a. When you informed the claimant of the discharge, what reason did you provide?

Was this a policy violation? ?

Yes

No

If Yes, please provide documented proof as necessary.

b. Was the claimant warned regarding this behavior?

?

Yes

No

 

 

Date(s) of warnings for this behavior?

 

 

 

 

 

 

The warning(s) was:

Oral

 

Written

 

Both

 

 

 

(Provide details regarding the nature of the warnings in Item 17. Attach documentation.)

c. Did the reason for discharge involve tardiness or attendance? ?

Yes

No If Yes, please provide the dates and reasons

regarding incidents.

 

 

 

 

 

 

 

 

 

17. COMPLETE THIS SECTION OR A SEPARATE SHEET FOR ADDITIONAL INFORMATION.

Name of the individual to contact for additional information:

 

Contact Telephone Number:

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

Signature

Name Printed

 

 

Title

 

Date Signed

 

 

 

 

 

 

 

 

Email address:

 

 

 

Fax number: (

)

 

 

(Please fax both front and back sides to DES)

NCUI500AB (Revised 06/30/2013)

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