Section 62 Initial Claim

• Library: Employer-Employee Law 2008 Forms

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 _____________...