Name *

First Name

Last Name

Phone *

(###)

###

####

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I agree to receive text messages from Maxson Firm, PLLC

Company's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Claimant's Names *

First Name

Last Name

What was the Start Date of Claimant's Employment?

MM

DD

YYYY

What was the End Date of Claimant's Employment?

MM

DD

YYYY

Was this Job:

Full Time

Part Time

Was this Work Primarily Performed in Kentucky?

Yes

No

Has the Job has Ended *

Yes

No

Was the Job Separation a: *

Discharge (firing)

Quit

Have you Received a Notice of a Potential Claim Against the Company from this Claimant Yet?

("Protest Form")

Yes

No

Have you Received a Notice of Determination saying the Claimant is/is not Qualified/Eligible to Receive Benefits? *

Yes

Has the Notice of Determination been Appealed to the Appeals Branch?

Yes

No

If an Appeal has already been Filed, have you been notified of the Administrative Case Number (the "AD" number)?

Each UI appeal is assigned a unique case number. This case number will start with an "AD" and then contain a series of numbers and then one or more letters at the end. This will be listed at the top of all appeal documents once generated.

Yes

No

Has an Appeals Branch Referee Hearing been Scheduled?

Yes

No

Has an Appeals Branch Referee Hearing Already been Held?

Yes

No

Has the Referee already Issued a Referee Decision?

Yes

No

Has the Referee Decision been Appealed to the Kentucky Unemployment Insurance Commission (KUIC)?

Yes

No

Has the KUIC Confirmed their Receipt of the Appeal and set the Deadlines for the Parties' Briefs?

The Appellant will have 10 days from the mail date to submit their Brief, and the Appellee with have 7 days thereafter.

Yes

No

Has the KUIC Issued an Order?

Yes

No

Has the KUIC Order been Appealed to Circuit Court?

Yes

No

Do you Understand Submitting this Form does not Create an Attorney-Client Relationship between you and Maxson Firm, PLLC? *

Yes, I understand

All Information Provided in this Form is True and Accurate to the Best of my Understanding at this Time. *

Correct