UC-21A

UC-21A

State of Connecticut - Department of Labor

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Form UC-21A: Section E - Unemployment Notice

Section E - Unemployment Notice

INSTRUCTIONS TO EMPLOYER:
It is your responsibility to give this entire packet to the separating employee at the time of separation, regardless of the reason for separation (see Section L below). If it is not possible to give this packet to the employee at the time of separation, then mail the packet to the employee’s last known address.

INSTRUCTIONS TO EMPLOYEE:
Go to www.FileCTUI.com, click on the link “Start a New Claim.”
DO NOT SEND A COPY TO THE DEPARTMENT OF LABOR

PLEASE BE SURE THAT ALL THE INFORMATION ENTERED BELOW IS CORRECT. IT IS EXTREMELY IMPORTANT TO PROVIDE THE EMPLOYER ACCOUNT NUMBER (BOX A).
A. Employer Account Number (required format ##-#####-0-00):*
B. Employer Name:*
C. Employer Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
D. Employee Name:*

First NameLast Name
E. Social Security Number (required format ###-##-####):*
F. NCCI Code (for use only if this employee was employed in a CONSTRUCTION TRADE):
G. Start Date:*

MonthDayYear
Date
H. Last Day Worked:*

MonthDayYear
Date
I. Return to Work Date (if definitive):

MonthDayYear
Date
J. Year to Date Earnings ($):
K. Wages for the Last Week of Work If Less than A Full Week ($):
L. Reason for Unemployment:*

Lack of WorkVoluntary LeavingDischarge/SuspensionLeave of AbsenceOther
M. Did or will this employee receive dismissal pay (i.e. Type 1. Severance 2. Vacation 3. Holiday 4. Other) after last day of work?

YesNo
If Yes, what type:
No. of Hours/days covered:
Amount ($):
Employer Signature:

Clear
Title:*
Date:*

MonthDayYear
Date
Phone Number:*
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Rev. 02/2025
Should be Empty: