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)

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

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)