Request for Extension to Worker Attachment- Unemployment Insurance

THIS FORM SHOULD ONLY BE USED TO EXTEND THE RETURN-TO-WORK DATE OF AN EXISTING ATTACHMENT PERIOD.

Extension of an existing attachment may be granted for up to two weeks upon proof of short-term circumstances beyond the employer’s control that prevent the worker from returning to work.

This form should NOT be completed by employees.

Company Name

Employer Account Number

Company Email

Reason for Request

Is this the company’s first request for an extension to worker attachment status?

Yes

Workers Returning to Work Since Original Period of Layoff

Have the workers listed returned to work since the original period of layoff?

Yes

Please list all employees on one form. Include the original return date for each employee listed.

Employee Name	Last 4 Digits of SSN	Last Day Worked	New Return Date

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