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.


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

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