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Any further details of qualifications for and/or the process and timelines for claiming the above benefit may be obtained from any local carrier. You should provide the following information with your Claim Form: 1. Your last name 2. Your full name 3. The number of months, or estimated number of months of employment for which you are claiming 4. The date on which you expect to reach layoff 5. The date on which you expect to be offered/discuss work 6. A description of the job duties for which you expect to be laid-off and a listing of the occupations you would prefer to work while in layoff 7. Your expected starting salary as of the date of layoff 8. Your employment location 9. Whether, prior to your layoff, you provided an employment contract which specified your job requirements or whether there were no job requirements at all 10. Who or which company should be contacted to notify you of your layoff 11. Whether you are eligible for a severance package 12. Whether you have a valid government issued identification which identifies you, the insured, or some other person with a similar name 13. The date on which you expect to be terminated. 14. A statement of the amount of premium you would have to contribute if you were terminated at the time the claim is filed as well as the maximum amount available under the premium waiver policy. In order to be eligible, you should be able to verify the following: Your last name 16. The number of months, or estimated number of months of employment for which you are claiming 17. The date on which you expect to reach layoff 18. The date on which you expect to be offered/discuss work 19. Whether you provide employment contract 18 months ago 20. Whether you provide a description of the job duties for which you expect to be laid-off 21. Whether your company provided you with a description of your job duties and your work demands. 22. Whether your company provided you with a severance package 25. A description of your job before you are laid off. 26. Whether the employer terminated you to reduce expenses. If the employer terminated you, the reason for the layoff should be listed in the layoff letter. If a notice of layoff was issued, the date of issuance should be provided. 27. Whether your company offered you severance and offered a minimum severance period. The maximum severance period available is 60 weeks. If you have less than 60 weeks remaining, there will be an additional 30-day waiting period.

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