Unemployment Insurance Employer Feedback Email Form
Business Name (Required)
UI Account Number (Optional)
Contact Name (Required)
Phone Number (Required)
Email Address (Required)
What unemployment topic below best relates to your question/concern? (Required)
-Select One-
Employee Charges Against UI Account
Document Received Re: Past Employee
Benefit Claims - Unemployment Law Clarification
Tax - Unemployment Law Clarification
Decision Received Re: UI Account
Employment and Wage Exclusions
Filing Requirements
Delinquent Tax Questions
Report Individual Who Refused Work
Not Sure
Additional Details About Refused Work
Please enter all of the following details about the refused work.
Name of Individual Who Refused Work
Last 4 Digits of Individual's SSN
Date Job Was Offered
Date Job Was To Start
Address of the worksite location (Line 1)
Address of the worksite location (Line 2)
City of the worksite location
State of the worksite location
-Select One-
WISCONSIN
ALASKA
ALABAMA
ARKANSAS
ARIZONA
CALIFORNIA
CANADA
COLORADO
CONNECTICUT
DIST/COLUMBIA
DELAWARE
FLORIDA
GEORGIA
HAWAII
IOWA
IDAHO
ILLINOIS
INDIANA
KANSAS
KENTUCKY
LOUISIANA
MASSACHUSETTS
MARYLAND
MAINE
MICHIGAN
MINNESOTA
MISSOURI
MISSISSIPPI
MONTANA
NORTH CAROLINA
NORTH DAKOTA
NEBRASKA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEVADA
NEW YORK
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VIRGINIA
VIRGIN ISLANDS
VERMONT
WASHINGTON
WISCONSIN
WEST VIRGINIA
WYOMING
Zip Code of the worksite location
Job title offered
Job duties offered (Max 100 characters)
Number of hours offered to work each week
Specific days/hours of work offered
Hourly rate of pay offered
$
If the individual was not to be paid hourly, explain how he/she would be paid
Reason given by the individual for refusing the job offer
Last day of work, if the individual previously worked for the employer
Question/Concern (Max 1,000 characters)
(Required)