Disability During Unemployment and Family Leave During Unemployment Inquiry Form

For general inquiries regarding Disability During Unemployment or Family Leave During Unemployment, please complete and submit this form. The information you provide will be transmitted securely. Please include as much detail as possible so that our staff can best assist you.

First name

Last name

Social Security Number

Telephone number

Email address

Verify email address

Email Address Anonymous Access

First date of disability (the first day you were unable to work)

Please provide a list of all the employers you worked for in the last 18 months and the last day you worked for each.

Employer name

Last day worked

Have you received temporary disability benefits from another program (for example: State Plan, Private Plan, other agency)? Value is not selected

What is your question/issue?

Please upload any relevant documentation, such as medical continuation forms, an out of State denial letter or Disability During Unemployment forms, or questionnaires issued for completion and return.

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DDU and FLDU Inquiry Form