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Date Received:

Date Postmarked/Faxed:

Effective Date:

UNEMPLOYMENT INSURANCE APPLICATION

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 Employment Development Department (EDD) 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.

Did you work in a state other than California during the

Yes

If yes, check the applicable box(es) below:

last 18 months?

State(s) Outside California, specify state(s):

AND / OR

Did you work in Canada during the last 18 months?

Canada

What is your Social Security number as given to you by

the Social Security Administration?

a) If the EDD assigned you an EDD Client Number

(ECN), please provide the ECN here. (An ECN is a

9-digit number beginning with 999 or 990.)

2A.

List any other Social Security numbers you have used.

2A.

What is your full name?

Last

First

Middle Initial

Is this the name that appears on your Social Security

Yes

card?

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

Last

Security card.

First

Middle Initial

List any other names you have used.

What is your birth date?

(mm/dd/yyyy)

What is your gender?

Male

Female

Would you prefer your written material in English or

English

Spanish

Spanish?

a) What is your preferred spoken language?

Have you filed a California Unemployment Insurance or a

Yes

Disability Insurance claim in the last two years?

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

a) If yes, list each type of claim and the most recent

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

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

DE 1101ID Rev. 3 (1-14) (INTERNET)

Page 1 of 12

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number:

10. Do you have a Driver’s License issued to you by a

10.

Yes

State/entity?

a) If yes, provide the name of the issuing State/entity and

Name of issuing State/entity:

your Driver’s License number.

Driver’s License Number:

If no, answer questions b-d:

b) Do you have an Identification Card issued to you by a

Yes

State/entity?

c) If yes, provide the name of the issuing State/entity and

Name of issuing State/entity:

your Identification Card number.

Identification Card Number:

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

Please Explain:

do you get to work?

11. What is your telephone number?

11.

a) If you are deaf, hard of hearing, or have a speech

TTY (Non-voice)

California Relay Service

disability and use TTY or California Relay to

communicate, check the appropriate box.

12. What is your mailing address?

12.

Street:

Apt.

(Include your city, State, and ZIP code)

City:

State:

ZIP Code:

13. Is your residence address the same as your mailing

13.

Yes

address?

a) If no, enter your residence address. (Include your city,

Street:

Apt.

State, ZIP code and apartment number.) A residence

City:

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

address.

State:

ZIP Code:

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

14.

County in which you live?

15. What race or ethnic group do you identify with? Check one of the following:

White

Black not Hispanic

Hispanic

Asian

American Indian/Alaskan Native

Chinese

Cambodian

Filipino

Other Pacific Islander

Guamanian

Asian Indian

Japanese

Korean

Laotian

Samoan

Vietnamese

Hawaiian

I choose not to answer

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

16.

Yes

I choose not to answer

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.)

17. 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

18. Are you a Military Veteran?

18.

Yes

DE 1101ID Rev. 3 (1-14) (INTERNET)

Page 2 of 12

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number:

19.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 and mailing address 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)Specify if you worked full-time or part-time.

f)How many hours you worked per week.

g)Check the appropriate “Yes/No” box if the employer is (or is not) a school or educational institution or a public or nonprofit employer where you performed school-related work.

NOTE: It is important that you report the employer name(s) and mailing address(es), period(s) of employment, and wages correctly. Failure to provide complete information will result in your benefits being delayed or denied.

a) Employer Name and Mailing Address

b) Dates Worked

c) Total Wages

d) How were you paid? (e.g.,

weekly, monthly, etc.)?

Name:

From:

Mailing Address:

To:

Street:

City:

State:

ZIP Code:

e) Did you work full-time or part-time?

F/T

P/T

f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprofit employer where you performed school-related work?

If yes, provide phone number

Yes

a) Employer Name and Mailing Address

b) Dates Worked

c) Total Wages

d) How were you paid? (e.g.,

weekly, monthly, etc.)?

Name:

From:

Mailing Address:

To:

Street:

City:

State:

ZIP Code:

e) Did you work full-time or part-time?

F/T

P/T

f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprofit employer where you performed school-related work?

If yes, provide phone number

Yes

a) Employer Name and Mailing Address

b) Dates Worked

c) Total Wages

d) How were you paid? (e.g.,

weekly, monthly, etc.)?

Name:

From:

Mailing Address:

To:

Street:

City:

State:

ZIP Code:

e) Did you work full-time or part-time?

F/T

P/T

f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprofit employer where you performed school-related work?

If yes, provide phone number

Yes

a) Employer Name and Mailing Address

b) Dates Worked

c) Total Wages

d) How were you paid? (e.g.,

weekly, monthly, etc.)?

Name:

From:

Mailing Address:

To:

Street:

City:

State:

ZIP Code:

e) Did you work full-time or part-time?

F/T

P/T

f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprofit employer where you performed school-related work?

If yes, provide phone number

Yes

DE 1101ID Rev. 3 (1-14) (INTERNET)

Page 3 of 12

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number:

19.Continued

a) Employer Name and Mailing Address

b) Dates Worked

c) Total Wages

d) How were you paid? (e.g.,

weekly, monthly, etc.)?

Name:

From:

Mailing Address:

To:

Street:

City:

State:

ZIP Code:

e) Did you work full-time or part-time?

F/T

P/T

f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprofit employer where you performed school-related work?

If yes, provide phone number

Yes

a) Employer Name and Mailing Address

b) Dates Worked

c) Total Wages

d) How were you paid? (e.g.,

weekly, monthly, etc.)?

Name:

From:

Mailing Address:

To:

Street:

City:

State:

ZIP Code:

e) Did you work full-time or part-time?

F/T

P/T

f) How many hours did you work per week?

g) Is this employer a school employer or a public or nonprofit employer where you performed school-related work?

If yes, provide phone number

Yes

20.	During the past 18 months did you work for any other	20	Yes	No
	employers not listed in question 19?	If yes, list the employer information for questions 19 a-g on a separate

		sheet of paper. Attach the additional sheet of paper to this application.

21.	If the EDD finds that you do not have sufficient wages in	21	Yes	No
	the Standard Base Period to establish a valid claim, do
	you want to attempt to establish a claim using the
	Alternate Base Period?
	For additional information about the Standard Base Period
	and the Alternate Base Period, visit the EDD website
	www.edd.ca.gov.

22.	During the past 18 months, which employer did you work	22. Employer name:
	for the longest?
	a) What type of business was operated by the employer?		a) Type of business:
	(Please be specific. For example, restaurant, dry
	cleaning, construction, book store.)
	b) How long did you work for that employer?		b) Years	Months
	c) What type of work did you do for that employer?		c)

23.	What is your usual occupation?	23.

24.	Is your usual work seasonal?	24.	Yes	No
	If yes, answer questions a-c:		If yes, answer questions a-c:
	a) When does the season usually begin?		a)		(mm/dd/yyyy)
	b) When does the season usually end?		b)		(mm/dd/yyyy)
	c) What other work-related skills do you have?		c)

DE 1101ID Rev. 3 (1-14) (INTERNET)

Page 4 of 12

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number:

Please provide information about 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.

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. If you worked for In-Home Supportive Services (IHSS), the welfare recipient for whom you provided the in-home supportive service is your employer, not the county. You may want to refer to your check stub(s) or W-2(s) to obtain the name of your employer.

Reminder: To file a claim, individuals must be out of work or working less than full time. You must provide information about the last employer you worked for as an employee. Do not include self-employment unless you have elective coverage.

25. What is the last date you actually worked for your very

25.

(mm/dd/yyyy)

last employer?

What are your gross wages for your last week of work?

a) $

For Unemployment Insurance purposes, a week

begins on Sunday and ends the following Saturday.

What is the complete name of your very last

b) Name:

employer?

What is the mailing address of your very last

Mailing address:

employer?

Street:

City:

State:

ZIP Code:

Is the physical address of your very last employer the

Yes

same as their mailing address? (A physical address

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

address.)

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

Physical address:

employer?

Street:

City:

State:

ZIP Code:

What is the telephone number of your very last

employer at their physical address?

What is the name of your immediate supervisor?

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.

26. Are you (directly or indirectly) out of work with any employer

Yes

(last employer or any employer in the 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:

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

How many employees left work?

Name:

d) Was there a spokesperson for the employees?

Yes

Phone:

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

b) Are you going to receive strike benefits?

Yes

Name:

Phone:

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Page 5 of 12

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number:

27. Are you currently working for or do you expect to work for

27.

Yes

any school or educational institution or a public or nonprofit

employer performing school-related work?

If yes, answer questions a-e:

a) Provide the following information for the school or

Name:

educational institution(s) or the public or nonprofit

Mailing Address:

employer(s).

Street:

City:

State:

ZIP Code:

Phone:

Name:

Mailing Address:

Street:

City:

State:

ZIP Code:

Phone:

b) Are you a substitute teacher for Los Angeles

Yes

Unified School District (LAUSD)?

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

Yes

d) Do you have reasonable assurance to return to

Yes

work after the recess period or the off track period

If yes, when?

(mm/dd/yyyy)

with any school or educational institution?

(mm/dd/yyyy)

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

the next off track period?

28. Do you expect to return to work for any former employer?

28.

Yes

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

29.

Yes

If yes, answer question a:

a) What date will you start work?

(mm/dd/yyyy)

30. Are you a member of a union?

30.

Yes

If yes, answer questions a-e:

What is your union name and local number?

Are you in good standing with your union?

Yes

c) Does your union look for work for you?

Yes

d) Does your union control your hiring?

Yes

Are you registered with your union as out of work?

Yes

DE 1101ID Rev. 3 (1-14) (INTERNET)

Page 6 of 12

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number:

31.

Are you currently attending, or do you plan on attending

31.

Yes

school or training?

If yes, answer question a-f:

If yes, answer questions a-f:

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

(mm/dd/yyyy)

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?

d) Phone:

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

e) Days and hours:

plan to attend, school?

f) Is your school or training program authorized or funded

Yes

by one of the programs listed in section f?

If yes, check only one box.

NOTE: If you completed apprenticeship training,

Workforce Investment Act (WIA)

Employment Training Panel (ETP)

complete questions a-f and mail your training

Trade Adjustment Assistance (TAA)

certificate with your CONTINUED CLAIM FORM,

California Work Opportunity and Responsibility to Kids

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

(CalWORKS)

Union Apprenticeship

Union Journey Level

32.

Are you available for immediate full-time work in your

32.

Yes

usual occupation?

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

Explanation:

full-time work.

33.

Are you available for immediate part-time work in your

33.

Yes

usual occupation?

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

Explanation:

part-time work.

34.

Are you currently self-employed, or do you plan to

34.

Yes

become self-employed? (Self-employment means you

have your own business or work as an independent

contractor.)

35. Are you now, or have you been in the last 18 months an

35.

Yes

officer of a corporation or union or the sole or major

stockholder of a corporation?

a) If yes, include name of organization and your title or

Name of Organization:

position.

Title/Position:

36.

Did you serve as an elected public official or Governor-

36.

Yes

exempt appointee in the last 18 months?

DE 1101ID Rev. 3 (1-14) (INTERNET)

Page 7 of 12

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number:

37. Are you currently receiving a pension?

37.

Yes

If yes, answer question a:

a) Are you currently receiving more than one pension?

Yes

If yes, proceed to question 38.

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

Yes

wages?

d) Is the pension a union pension or a pension funded by

Yes

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 months?

Yes

38. Will you receive any additional pension(s) in the next

38.

Yes

twelve months?

If yes, answer questions a-b:

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

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

(mm/dd/yyyy)

39. Are you receiving, or do you expect to receive, Workers’

39.

Yes

Compensation?

If yes, answer questions a-d:

a) Who is the insurance carrier?

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

b) Phone:

c) What is the case number, if known?

d) What are the dates of your claim, if known?

From:

(mm/dd/yyyy)

To:

(mm/dd/yyyy)

40. Have you received or do you expect to receive, any payments from your last employer, other than your

Yes

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

If yes, provide the information in sections A-D. If you received severance pay as a lump sum, complete sections A-C (in section C, report the date the lump-sum payment was made).

A.	B.	C.	D.
TYPE OF PAYMENT	AMOUNT OF PAYMENT	PAID FROM	PAID TO
(Example: vacation pay)	(Example: $600)	(Date: mm/dd/yyyy)	(Date: mm/dd/yyyy)

DE 1101ID Rev. 3 (1-14) (INTERNET)

Page 8 of 12

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number:

41.Are you a U. S. Citizen or National? If no, answer question a:

a)Are you registered with the United States Citizenship and Immigration Services (USCIS, formerly INS) and authorized to work in the United States?

b)Were you legally entitled to work in the United States for the last 19 months?

41.

Yes

If no, answer question a:

a)	Yes	No
b)	Yes	No

IMPORTANT: If you answered “yes” to question “a” above, you must select one of the USCIS documents listed in 41A through 41H below and provide the applicable document information.

41A. Permanent Resident Card (I-551)		41A. Permanent Resident Card (I-551)
1)	Alien Registration Number (A#)	1) A#
		The Alien Registration Number must be 7 to 9 digits long.
		Enter numeric digits only.
2)	Permanent Resident Card Number (CARD#)	2)
		The CARD# must be 13 characters long. Enter 3
		alphabetic characters followed by 10 numeric digits. If your
		current card was issued to you before December 1997,
		leave this blank.

NOTE: The CARD# is on the back of the card, next to your photo, under the DOB and the EXP date.


3)	Expiration Date (EXP)	3)		(mm/dd/yyyy)

41B. Employment Authorization Card (I-766)		41B. Employment Authorization Card (I-766)
1)	Alien Registration Number (A#)	1)	A#
			The Alien Registration Number must be 7 to 9 digits long.
			Enter numeric digits only.
2)	Expiration Date	2)		(mm/dd/yyyy)

41C. Refugee Travel Document (I-571)		41C. Refugee Travel Document (I-571)
1)	Alien Registration Number (A#)	1)	A#
			The Alien Registration Number must be 7 to 9 digits long.
			Enter numeric digits only.

2) Expiration Date

2)(mm/dd/yyyy)

DE 1101ID Rev. 3 (1-14) (INTERNET)

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UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number:

41D.

Arrival/Departure Record (I-94)

41D.

Arrival/Departure Record (I-94)

Arrival/Departure Number

The Arrival/Departure Number must be 11 digits long. Enter

numeric digits only.

Expiration Date

(mm/dd/yyyy)

41E.

Re-entry Permit (I-327)

41E.

Re-entry Permit (I-327)

Alien Registration Number (A#)

The Alien Registration Number must be 7 to 9 digits long.

Enter numeric digits only.

Expiration Date

(mm/dd/yyyy)

41F.

Unexpired Foreign Passport

41F.

Unexpired Foreign Passport

Arrival/Departure Number

The Arrival/Departure Number must be 11 digits long. Enter

numeric digits only.

Passport Number

The passport number must be 6 to 12 alphanumeric

characters. It is usually found on the top right corner of the

document.

Visa Number

The Visa Number must be 8 numeric digits.

Expiration Date

(mm/dd/yyyy)

41G. Arrival/Departure Record (I94) in Unexpired Foreign

Passport

Arrival/Departure Number

The Arrival/Departure Number must be 11 digits long. Enter

numeric digits only.

Passport Number

The passport number must be 6 to 12 alphanumeric

characters. It is usually found on the top right corner of the

document.

Visa Number

The Visa Number must be 8 numeric digits.

Expiration Date

(mm/dd/yyyy)

41H. Other Document (not listed in Section A to G)

Alien Registration Number (A#)

The Alien Registration Number must be 7 to 9 digits long.

Enter numeric digits only.

Arrival/Departure Number

The Arrival/Departure Number must be 11 digits long. Enter

numeric digits only.

Expiration Date

(mm/dd/yyyy)

Document Description

Document Description:

DE 1101ID Rev. 3 (1-14) (INTERNET)

Page 10 of 12

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number:

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?

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?

Yes

If yes, answer questions a-d:

Yes

e) 1)	An employee who is unable to work as a direct result of
	the disaster.
2)	An individual who was scheduled to start work for an
	employer, but could not because of the disaster.
3)	A self-employed individual who is unable to work as a
	direct result of the disaster.
4)	An individual who intended to begin self-employment,
	but could not because of the disaster.
5)	An individual who became head of household as a result

of the disaster.

h)Street:

City:

State:

Zip Code:

DE 1101ID Rev. 3 (1-14) (INTERNET)

Page 11 of 12

UNEMPLOYMENT INSURANCE APPLICATION

Social Security Number:

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:	EDD
	P.O. Box 12906
	Oakland, CA 94604-2909
	NOTE: Extra postage is required.

By FAX to the following telephone number:	1-866-215-9159

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 1-800-300-5616	Spanish 1-800-326-8937	Mandarin 1-866-303-0706

TTY (Non Voice) 1-800-815-9387	Cantonese 1-800-547-3506	Vietnamese 1-800-547-2058

Date Submitted:

Mail or

Fax

KEEP THIS PAGE FOR YOUR RECORDS

DE 1101ID Rev. 3 (1-14) (INTERNET)

Page 12 of 12

Question	Answer
Form Name	Unemployment Insurance Application Form
Form Length	12 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min
Other names	de1101i, 1997, California, printable california unemployment application

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