Section 62 Initial Claim

• Library: Employer-Employee Law 2008

This is a representation of the questions asked when a claimant files an initial claim by telephone or on the Internet. This is not available as an actual form.

FIRST NAME_________ LAST NAME__________ SOC-SEC-NO._________ L.O.

STREET_____________ CITY _____________ STATE______________ ZIP

COUNTY_______ PH________ BIRTH________ SEX___ A___ B___ C___ HD___ ED

LAST EMPLOYER__________________________ POTREC

STREET_____________ CITY _____________ STATE______________ ZIP

LDW____ SEP____ ILW 2Q 3D 4S 5LD 6LA R___ RECALL_____ SIC_____ TNR

EFFECTIVE DATE_______ T/P_____ PROGRAM_____ DATE FILED_____ BY

CONTACTS_______ TO__________ DETERMINATION________ TRANSFERS

PENSION TYPE____ PENSION AMT____ VAC/HOLIDAY AMT___ FROM___ TO

DURING THE LAST 18 MONTHS HAVE YOU:

WORKED FOR THE FEDERAL GOVERNMENT?

PERFORMED ANY ACTIVE MILITARY SERVICE? ...