APPLICATION FOR UNEMPLOYMENT BENEFITS

HAWAII INSULATORSSUPPLEMENTAL UNEMPLOYMENT BENEFITS TRUST

Part I– THIS SECTION IS FOR MEMBER INFORMATION ONLY – PLEASE PRINT
LAST NAME / FIRST NAME / MIDDLE NAME / DATE
MAILING ADDRESS / CITY STATE ZIP CODE
SOCIAL SECURITY NUMBER
__ __ / DAYTIME PHONE NUMBER / BENEFITS FOR WEEK ENDING
Part II– APPLYING FOR INITIAL WAITING PERIOD BENEFIT PAYMENT – ATTACH REQUIRED DOCUMENTS LISTED BELOW
SUBMIT DOCUMENTS
FROM ONE OF THE
BOXES TO THE RIGHT: / STATE DEPT OF LABOR &
INDUSTRIAL RELATIONS
UNEMPLOYMENTINSURANCE
DETERMINATIONOF INSURED
STATUS / DEPT OF LABOR NOTICE
STATING NON PAYMENT
FOR MM/DD/YY PENDING
MONETARY DETERMINATION
AND
LETTER FROM EMPLOYER(S)
STATING YOU ARE
UNEMPLOYED AS OF MMDDYY / COPY OF
UNEMPLOYMENT
CHECK STUB
AND
LETTER FROM EMPLOYER(S)
STATING YOU ARE
UNEMPLOYED AS OF MMDDYY
ALSO INCLUDE: / CERTIFICATION BY THE UNION THAT
INVOLUNTARY TERMINATION HAS
OCCURRED (UC-226 FORM) / AND / YOU MUST MEET THE CONDITIONS
REQUIRED FOR STATE
UNEMPLOYMENT COMPENSATION
Part III– APPLYING FOR 2ND WEEKLY BENEFIT PAYMENT – ATTACH REQUIRED DOCUMENTS LISTED BELOW
______CERTIFICATION OR PROVIDE FACTUAL
Initials INFORMATION THAT YOU ARE NOT &
HAVE NOT BEENEMPLOYED WHICH
WOULD CAUSE BENEFITS TO CEASE / STATE DEPT OF LABOR &
INDUSTRIAL RELATIONS
UNEMPLOYMENT INSURANCE
DETERMINATIONOF INSURED STATUS
(IF NOT ALREADY SUBMITTED) / AND / COPY OF
UNEMPLOYMENT
CHECK STUB
Part IV– APPLYING FOR SUBSEQUENT WEEKLY BENEFITS – ATTACH REQUIRED DOCUMENTS LISTED BELOW
______CERTIFICATION OR PROVIDE FACTUAL INFORMATION ON A
Initials WEEKLY BASIS THATYOU ARE NOT & HAVE NOT BEEN
EMPLOYED WHICH WOULD CAUSE BENEFITS TO CEASE / AND / COPY OF UNEMPLOYMENT
CHECK STUB
Part V– PAYMENT INSTRUCTIONS – CHECK ONE BELOW
ALL COMPLETED AND SIGNED SUB APPLICATIONS RECEIVED BY WEDNESDAY OF EACH WEEK WILL BE PROCESSED ON
THURSDAY, CHECKS WILL BE MAILED ON FRIDAY OF THE SAME WEEK. IF YOU PREFER TO PICK UP YOUR CHECK ON FRIDAY,
PLEASE CHECK THE BOX BELOW. FOR HOLIDAYS THAT FALL ON FRIDAY, CHECKS WILL BE AVAILABLE ON FOLLOWING MONDAY.
PLEASE DO NOT MAIL MY CHECK. I WILL PICK UP MY CHECK FROM THE TRUST OFFICE.
Part VI– SUBMISSION OF APPLICATION – ATTACH ALL REQUIRED DOCUMENTS TO AVOID ANY DELAYS IN RECEIVING
YOUR BENEFIT PAYMENT
MAIL TO THE TRUST FUND OFFICE:
HAWAII INSULATORS SUPPLEMENTAL UNEMPLOYMENT BENEFITS TRUST
1440 KAPIOLANI BLVD. SUITE 800
HONOLULU, HI 96814 / OR / DROP OFF AT THE SAME LOCATION:
TUESDAYS, WEDNESDAYS AND FRIDAYS
BETWEEN THE HOURS OF 9:00AM – 3:00PM
FAX TO: 441-8757
YOUR SIGNATURE IN FULL
X / DATE
FOR OFFICE USE ONLY
CHECK DATE / CHECK NUMBER / CHECK AMOUNT / DATE MAILED / DATE PICKED UP