The interactive sample form shown below will display a detailed description when you move your mouse cursor over each section. A complete description of all sections is provided beneath the form.
Notice to Base Period Employer: indicates an unemployment claim has been filed by an individual and you are a base period employer who reported wages that are being used to establish the claim.
Claimant: name of the individual filing for unemployment benefits.
Soc. Sec. #: provided by the individual at the time of claim filing.
Date: mailing date of the Notice to the Base Period Employer.
Effective Date: the effective date or beginning date of the claim.
Employer Acct #: your employer account number that you report the individual's wages under. If the employer account number is shown as "9999999.95", this indicates that information provided by the individual was not sufficient to correctly identify your account number or if your employer account is with another State.
Base Period: in most circumstances, this will be the first four of the last five completed calendar quarters prior to an employee filing a valid claim for benefits; not the dates the claimant has worked.
Employer name and address provided by the individual; in some case, your correct mailing address may not be known.
Return To: the mailing address where the Notice of Claim Filed is returned; this may either be a Las Vegas address or a Carson City address.
Benefits for Which Claimant Is Eligible: benefit amount the individual is eligible to receive; Weekly Amount: the weekly amount the individual may receive each week; and Maximum Amount: the total amount of benefits the individual may be entitled to receive during the benefit year.
Your Potential Liability: for the benefit year listed, an employer’s potential liability is the total dollar amount you may be charged for the claim. The percentage is your percent of wages used in the base period. Base period employers are liable for their percentage of any benefits paid during the benefit year. An employer who contributed 75% or more of the total base period wages will be charged 100% of all benefits paid; whereas a reimbursable employer will be billed their portion of benefits paid. If there is no information in this area, you are not a base period employer and will not be charged for benefits paid if the claimant is eligible.
Your Reported Wages Are: The calendar quarters used to establish the claim for benefits. These wages have been reported quarterly by you and are used in establishing a claim for unemployment insurance. If there is no information in this area, you are not a base period employer and will not be charged for benefits paid if the claimant is eligible.
The reason provided by the individual for the separation from employment.
This section is for you to provide information regarding the individual’s separation from employment. It is important that you provide all relevant facts in order to receive a copy of the decision and to protect your appeal rights.
a) Mark the box that appropriately classifies the separation; if none of the boxes fit the separation, leave blank and explain in the ’additional comments’ area below.
b) Dates the individual was considered an employee: start date to last date worked. If separation date was different from the last date worked, provide the separation date in Quit or Discharge area.
c) If the individual quit, explain the reason that the individual gave to you for quitting. Attach letter of resignation, if available.
d) If the individual was discharged, please explain the reason the individual was discharged; specifically the final incident that led to the discharge and when it occurred. Provide any copies of warnings issued, policies violated and/or all other supporting documentation.
This section is for you to report if the individual received any separation pay (do not report their last pay check received):
a) Indicate yes or no if the individual will receive vacation pay; if yes, provide the total dollar amount.
b) The date the vacation pay was paid to the individual.
c) Indicate yes or no if the individual will receive severance pay; if yes, provide the total dollar amount.
d) The date the severance pay was paid to the individual.
e) Indicate yes or no if the individual will receive wages in lieu of notice pay; if yes, provide the total dollar amount.
f) The date the wages in lieu of notice pay was paid to the individual.
g) The total gross amount, before taxes, the individual earned weekly; if amount varied, provide an average weekly amount.
h) Total amount of hours the individual worked each week; if amount varied, provide the average weekly number of hours worked.
Additional comments area to provide information regarding the individual's employment with you. If the space provided is not adequate, attach additional supporting documents. It is important that you provide all relevant facts about the separation with this notice to protect your rights in this eligibility decision.
The Employer Notice of Claim Filed must be completed, signed and returned by a company official within eleven (11) calendar days to return this notice from the mailing date, to protect your rights in this eligibility decision and to receive a copy of any eligibility decision issued.
A contact name must be provided. A Division Representative will speak with the contact person to obtain additional information.
An authorized company official must sign the notice and provide their title. The telephone number provided may be the contact name's number or your main number.
If you should have additional questions regarding this notice, please call the number indicated on the form.
You may fax the notice to the fax number provided on the form. (E-mail responses can not be accepted at this time.)
