Document Number: UCB-18823-E
Description: This form is used by employers who laid off employees due to the public health emergency declared by Executive Order 72 (COVID-19 Coronavirus) and may qualify for relief of Unemployment Insurance (UI) benefit charging.
When employers receive a Separation Notice (UCB-16) for an employee, and the reason they are off work is due to COVID-19, employers will need to submit this form to request relief of charging. (Note: Do not submit this form with Separation Notice response).
Forms should be submitted within 30 days after the initial claim is filed.
Comments: Email completed form(s) as encrypted documents. Instructions: In Microsoft Word, use the "Protect Document – Encrypt with Password" option from the "File" menu. If you're using an Excel file for your participant list, the process is the same, but the button will read "Protect Workbook" instead of "Protect Document". Please send us the password for the protected document in a separate email. Please include the Employer UI Account No. in the subject line of both emails.
Content Contact: Benefit Operations Staff
Document Attachment: UCB-18823-E (Electronic Version - Word/307 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.