Question Title

* 1. Member Name and Contact Phone Number

Question Title

* 2. Employer, Position, Time on Job

Question Title

* 3. When was your last scheduled day of work? 

Question Title

* 4. Anticipated return to work date?

Question Title

* 5. Are you experiencing a loss of income due to your employer's limited operations?

Question Title

* 6. If you answered YES to Q5: Estimated monthly income loss? Please explain.

Question Title

* 7. Do you have any supplemental income?

Question Title

* 8. If you answered YES to Q7: What type of supplemental income and amount? (Example: SSI, Disability, Cash Tips, etc.)

Question Title

* 9. Have you filed for UIA (unemployment) Benefits?

Question Title

* 10. If you answered YES to Q9: Will you be receiving UIA (unemployment) benefits? Amount? Please explain.

T