UNEMPLOYMENT INSURANCE APPLICATION
DE 1101 I Rev. 6 (11-03) (INTERNET)
Page 1 of 8
For Department Use Only
PRE APPLICATION QUESTIONS MUST BE COMPLETED
A. Were you in the military during the last 18 months?
B. Did you work for an agency of the federal government during the last 18 months?
C. Did you work in a state other than California during the last 18 months?
D. Have you applied for unemployment insurance benefits in another state during the
last 12 months?
E. Did your employer or union give you a claim form for unemployment insurance
If you answered NO to all of the above questions (A through E) proceed.
If you answered YES to any of the above questions (A through E) do not complete this form, call 1 (800) 300-5616.
PLEASE ANSWER ALL QUESTIONS ON EACH PAGE
If a question is not answered or is incomplete it may delay or prevent the filing of your claim, or cause benefits to be
• Please complete this form with blue or black ink only.
• Please print or type information.
The answers you give to the questions on the application must be true and correct. You may be subject to penalties if you
make a false statement or withhold information.
This application will take you approximately 30 minutes to complete.
1. What is your Social Security Number as given to you by
the Social Security Administration?
If EDD assigned you an EDD Client Number (ECN),
please provide the ECN here and also provide your
Social Security Number in item 2 below. (An ECN is a
9-digit number beginning with 999.)
1. __ __ __ - __ __ - __ __ __ __
2. List any other Social Security Numbers you have used.
2. __ __ __ - __ __ - __ __ __ __
__ __ __ - __ __ - __ __ __ __
3. Have you ever filed a California Unemployment
Insurance or Disability Insurance claim?
a) If yes, please list