Step 1

1. This week beginning Monday XX/XX/XX, how may days have you worked? 0~7

2. This week, beginning Monday XX/XX/XX, were your gross earnings more than $504? Yes No

3. What was the last day that you’re worked? XXXX-XX-XX

4. Was your employment status impacted by COVID-19? Yes No

Step 2

Your mailing address

1. Did you work in New York State in the last 18 months? Yes No

2. Did you only work in New York State, one or more states other than New York, or did you not work?

I did not work int the past 18 months

I worked in 2 or more state

I only worked in New York

3. Do you currently live in New York State? Yes No

4. Were you discharged from the military within the last 18 months? Yes No

5. Was your last employment as a federal civilian employee whose last duty station was outside the United States? Yes No

Step 3

Your Name

First Name

Middle Initial

Last Name

Any other last name under which you worked during the last 18 months (optional):

Date of Birth

XXXX-XX-XX

Social Security Number

New York State Driver’s License or the number of you’re NYS Non-Driver Photo ID

I don’t have a NY Driver’s License or NYS Non-Driver Photo ID Card

How many employers have you worked for in the past 18 months?

Step 4

Your mailing address

Enter the number and street name or enter “P.O. Box” and the number

City

State

Zip Code

Telephone

Are you a veteran? Yes No

Are you a citizen of the U.S.? Yes No

Please enter your Alien Registration number (numbers after the letter “A”)

**You have completed the Unemployment Insurance Application section. If you are deemed ineligible, you may still qualify for Pandemic Unemployment Assistance(PUA). Please complete the following PUA

section to help us process your claims faster.**

Pre-Step 5

Information Regarding PUA

On March 27, 2020, the President of the United States signed a law that provides additional Unemployment Insurance (UI) assistance to workers impacted by COVID-19. This new law also provides Pandemic Unemployment Assistance (PUA). PUA extended eligibility for individuals who have traditionally been ineligible for UI benefits (e.g., self-employed workers, independent contractors).

WHO IS ELIGIBLE TO FILE FOR PUA?

-You were diagnosed COVID-19(coronavirus): or

-A member of the household who is diagnosed with COVID-19; or

-You are providing care for a family or household member diagnosed with COVID-19; or

-You are the primary caregiver for a child or other person who is unable to attend school or another facility due to COVID-19; or

-You are unable to reach your place of employment because of imposed quarantine: or

-You are unable to reach your place fo employment because you were advised by a health care provider to self-quarantine; or

-You were scheduled to start work and do not have a job as a result of COVID-19: or

-You became the “breadwinner” or major support provider for your household because the previous breadwinner or provider died from COVID-19; or

-You quit your job because of COVID-19; or

-Your place of employment closed because of COVID-19; or

-You are self-employed, seeking part-time employment, or do not otherwise qualify for benefits.

WHAT IS THE RELATIONSHIP TO REGULAN UI CLAIMS?

A Person may file under the PUA Program; however, PUA in NOT payable if the person is eligible for unemployment compensation under any state or other federal program.

HOW LONG IS PUA PAYABLE

PUA benefits are available for up to 39 weeks. The total number of weeks must include any weeks for which you receive regular Unemployment Insurance benefits or extended benefits under any federal or state law.

IF I AM APPROVED, HOW DO I CLAIM WEEKLY BEBEFITS?

Claim PUA benefits online by using the Department of Labor’s website: www.labor.ny.gov/signin

After you are signed in, you can access your weekly certification form by clicking on the menu (3-lined) button on the upper left of the screen next to the page title. You will see a menu (list) of links. Click the link labeled “My Online Forms.” You will see a PUA certification form that you must complete. You may also reach your Online Forms from the My Online Services Homepage.

If you are denied Pandemic Unemployment Assistance benefits, you have a right for a hearing before an administrative law judge at no cost or obligation to you.

Step 5

Step 5

Pandemic Unemployment Assistance

Do you have the ability to telecommute with pay? Yes No

Are you receiving paid sick leave or other paid leave benefit? Yes No

Did your place of employment full-time or self-employment close, partially or fully, as a direct result of COVID-19? Yes No

Are you otherwise able and available to work? Yes No

SUBMIT

Submission Confirmed

Thank you for submitting your unemployment insurance claim with the New York State Department of Labor.

To Complete your claim, a Department of Labor Call Center will call you within 72 hours. You do not need to contact the Department of Labor — We will contact you at the number that is listed on your claim. To verify that a caller is from the Department fo Labor, They will verify the date you filed your claim.

**IMPORTANT – READ AND PRINT THIS PAGE**

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