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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 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 not working is due to a quit, some employers will need to submit this form to request relief of charging if the initial claim relates to the public health emergency declared by Executive Order 72. (Note: Do not submit this form with Separation Notice response).
Employers should submit forms within 30 days after the initial claim is filed to ensure timely processing. Emergency Rule 2112 sets a deadline of the latter of May 14, 2021 or 30 days after receiving notification of the claim.
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/160 KB)
Note: If you need this form in an alternate format, please send a message to the Content Contact listed above.