Attachment D to UIPL No. 30-02, Change 2

Request for Employer Information - (Sample)
Employer Name and Address:	Claimant Name: Social Security Number:
The above-named claimant has filed a claim for Temporary Emergency Unemployment Compensation, which is available to displaced airline and related workers. To determine this individual’s eligibility, we need information from you concerning the nature of your business and the cause of the individual’s separation from employment with you during the following period: [insert base period] SECTION I – TYPE OF EMPLOYMENT Please answer “yes” or “no” to the following questions/statements and also complete Section II below: 1. If you are an Air Carrier with a certificate issued under Chapter 411 of Title 49 of the United States Code, check “yes” and proceed to Section II. Yes __ No __ 2. Does this company/business have facilities on-site at an airport or off-site nearby that are integrally connected to operations at the airport? Yes __ No __ If “yes” describe_______________________________________________________________ ________________________________________________________________________________ 3. This company/business provides one of the following to an airline or to a supplier or upstream producer to an airline for the airline’s use: a. Value-added production processes, including final assembly, finishing, or packaging of articles. Yes __ No __ b. Component parts or other articles. Yes __ No __ c. Contract services. Yes __ No __ If you answered “yes” to any statement above, please name at least one airline or company that you provided the product or service to._____________________________ If you name a company, please name at least one air carrier they supply._________ _________________________________________________________________________________ SECTION II – REASON FOR SEPARATION 1. Was the above-named individual laid-off because of a loss of business, in whole or in part, because of: a. The reductions in airline service following the terrorist actions of September 11, 2001 or resulting security measures. Yes __ No __ b. The closure of an airport in the U.S. as a result of such terrorist action or security measures. Yes __ No __ c. The conflict with Iraq. Yes __ No __ Please provide any facts supporting your answers. Attach additional sheet if necessary. ______________________________________________________________________
Name:___________________________Title: _________________________Date:____________