For claimants and employers to submit back pay information Who is submitting this claim? * Claimant Employer Employers can submit multiple entries in a spreadsheet. This spreadsheet can be completed and uploaded below if you have multiple employees you wish to report Individual Information Your SS# * Your first name * Your last name * Your Phone Number Your email address Have you filed a claim for unemployment? * Yes No Were you employed part time or full time? * Full time Part time What was your last day worked? * Did you receive pay (other than wages) after the last day you worked? * Yes No Did you quit rather than accept payment from your employer in order to prevent a reduction in unemployment benefits? * Yes No Did you decline payment from your employer to prevent a reduction in unemployment benefits? * Yes No Name of Employer * Address of Employer Please check from the boxes for payment type (may select more than one) * Vacation/PTO Severance/Wages in Lieu of Notice Sick Pay Work Comp (TTD) Supplemental Pay Paycheck Protection Program (PPP) Families First Coronavirus Response Act (FFCRA) - This is for weeks not already submitted on your weekly claim. Example: Benefits were paid out before you discovered your employer would pay you through the FFCRA. Other (please describe) Vacation/PTO Information Time frame to which payment applies Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid Severance/Wages in Lieu of Notice Time frame to which payment applies Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid Sick Pay Time frame to which payment applies Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid Work Comp (TTD) Time frame to which payment applies Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Supplemental Pay Time frame to which payment applies Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid Paycheck Protection Program (PPP) Time frame to which payment applies Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid Families First Coronavirus Response Act (FFCRA) This is for weeks not already submitted on your weekly claim. Example: Benefits were paid out before you discovered your employer would pay you through the FFCRA. Time frame to which payment applies Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid Other Payment Type Describe Other Payment Type Time frame to which payment applies Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid Employer Information Select type of employer identification Unemployment Insurance Employer Account Number FEIN FEIN Number * Unemployment Insurance Employer Account Number * Business Information Business Name * Business physical address * Business contact name * Business contact phone number Business Submission Type * Submitting one employee's information Submitting spreadsheet with multiple entries Spreadsheet Submission Spreadsheet Upload * Upload More informationFiles must be less than 5 MB. Allowed file types: xls xlsx. Single Employee Submission Employee SS# * Employee first name * Employee last name * Has the employee filed a claim for unemployment? * Yes No Is the employee part time or full time? * Full Time Part Time Last day employee worked * Did the employee receive pay (other than wages) after the last day worked?* * Yes No Did the employee quit rather than accept payment in order to prevent reduction in unemployment benefits? * Yes No Did the employee decline payment to prevent reduction in unemployment benefits? * Yes No Payment Types Select payment type * Vacation/PTO Severance/Wages in Lieu of Notice Sick Pay Work Comp (TTD) Supplemental Pay Paycheck Protection Program (PPP) Families First Coronavirus Response Act (FFCRA) - This is for weeks not already submitted on your weekly claim. Example: Benefits were paid out before you discovered your employer would compensate you with funds received through the FFCRA. Other (please describe) ______ Vacation/PTO Information Time frame to which payment applies: Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid: Severance/Wages Information Time frame to which payment applies: Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid: Sick Pay Time frame to which payment applies: Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid: Work Comp (TTD) Time frame to which payment applies: Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid: Supplemental Pay Time frame to which payment applies: Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid: Paycheck Protection Program (PPP) Time frame to which payment applies: Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid: Families First Coronavirus Response Act (FFCRA) This is for weeks not already submitted on your weekly claim. Example: Benefits were paid out before you discovered your employer would pay you through the FFCRA. Time frame to which payment applies: Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid: Other Describe other pay * Time frame to which payment applies: Date payment was issued Number of hours paid: required if hourly rate provided Hourly rate of employee: required if number of hours paid Gross wages paid: Leave this field blank Submit Individual
