Employment and Emploi et PROTECTED WHEN COMPLETED - B

Social Development Canada Développement social Canada

ANNEXE 1

NAME
QUIT (VOLUNTARY SEPARATION FROM EMPLOYMENT)
SOCIAL INSURANCE NUMBER
COMPLETE AND SEND WITH YOUR APPLICATION FOR BENEFIT.

IN ORDER TO MAKE A FAIR DECISION ON YOUR CLAIM IT IS ESSENTIAL THAT YOU PROVIDE AN ACCURATE ACCOUNT OF THE REASON(S) THAT LED YOU TO
VOLUNTARILY LEAVE YOUR EMPLOYMENT. EMPLOYER CONCERNED: LAST DAY WORKED:
(TO BE COMPLETED BY ESDC AS REQUIRED) YOUR CLAIM FOR BENEFIT WILL BE ADJUDICATED WITH THE FACTS PROVIDED. ANY OMISSION MAY RESULT IN AN
UNFAIR DECISION AND MAY DISQUALIFY YOU FROM BENEFITS TO WHICH YOU MAY HAVE OTHERWISE BEEN ENTITLED.

A - GENERAL QUESTIONS
b) Please give last day worked. Year Month Day
1 - a) Name, address and telephone number of employer that you left voluntarily.

2 - What was your reason for quitting your employment? If more than one reason is applicable, please list your reasons in order of priority.

3 - Did you take action to rectify the situation/problem that prompted you to quit your employment?

YES - If yes, please specify NO -If no, please give your reason(s) in detail.

4 - Did you discuss the situation/problem with your employer prior to quitting your employment?

YES - If yes, what was the result of this discussion? NO - If no, why did you quit prior to discussing your situation/problem? Please explain your reason(s) in detail.

5 - What efforts did you make to look for other work prior to quitting?

6 - Have you been looking for work since you quit?

YES - If yes, give details of your job search. NO - If no, explain.

B - OTHER EMPLOYMENT

7 - Did you voluntarily leave your job because of

NO - If no, proceed to Section C YES - If yes, answer the questions below
another job offer?

a) What is the name, address and telephone number of this prospective employer?

Year Month Day

b) What date were you scheduled to start your new employment?

c) Why was this offer withdrawn?

NOTE: It would be in your own interest to obtain confirmation of the above from the prospective employer and submit it to this office as soon as possible.

C - HEALTH REASONS

8 - Did you quit your employment due to health reasons? NO - If no, proceed to Section D YES - If yes, answer the questions below

a) What are the medical reasons that prompted you to quit your employment

b) Did you consult your doctor prior to quitting? NO YES

c) Did your doctor advise you to quit your employment. NO YES - If yes, give details

d) Did you request a leave of absence from your

YES NO - If no, why didn't you request one? Please explain in detail.
employer prior to leaving your employment?

NOTE: It would be in your own interest to obtain medical proof of the above from your doctor and submit it to this office as soon as possible.
D - ILLNESS IN THE FAMILY

9 - Did you quit your job due to illness in the family? NO - If no, proceed to Section E YES - If yes, answer the questions below

a) What is your relationship to the sick person?

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 b) Was your presence by the sick person essential? NO YES - If yes, specify

c) Was there anyone else who could have taken NO

your place? Please explain. YES

YES - If yes, was it denied? YES NO

d) Did you try to obtain a leave of absence?
NO - If no, why was one not requested? Please explain in detail.

E- RELOCATION
10 - Did you quit your employment due to a relocation
to another area? NO - If no, proceed to Section F YES - If yes, answer the questions below

a) Please give reason(s) for

the move.

he/she is transferred by
b) If the reason is due to a spousal relocation, specify he/she obtained new employment
his/her employer

i) What date did he/she start work? Year Month Day

ii) Is this permanent employment? YES NO - If not, give probable duration

YES - If yes, what efforts to seek

11 - Did you make any effort to find employment at your NO - If no, why were no efforts made? Explain.
employment did you make?
new location before leaving?
Please specify.

12 - Due to your relocation have there been any days or

weeks you were not available to accept employment? NO YES - If yes, please give dates.

13 - Do/did you require child care arrangements? NO YES Give date arranged

F - EARLY RETIREMENT

Did you choose to take early retirement? NO - If no, proceed to Section G YES - If yes, answer the questions below

14 - Did you take early retirement due to health reasons? NO YES - If yes, answer the questions below

a) What are the medical reasons that prompted you to retire?

b) Did you consult your doctor prior to retiring? NO YES

c) Did your doctor advise you to retire from your NO YES - If yes, specify.
employment?

NOTE: It would be in your own interest to obtain medical proof of the above from your doctor and submit it to this office as soon as possible.
15 - If you took early retirement because the job became too heavy, did you request lighter work?

YES - If yes, with whom did you discuss this and what were the results of your discussion?

NO - If no, why did you not make this request? Please explain.

16 - Did you look for other employment prior to retiring?

YES - If yes, please provide name and dates of employer(s) contacted.

NO - If no, why did you not do so?

17 - Did your employer have a written policy regarding If yes, please specify the
compulsory retirement? NO YES mandatory retirement age
The information you provide on this form is collected under the authority of the Unemployment Insurance Act and will be used to discuss your claim for benefits. This information will
be retained in the Personal Information Bank(s) entitled "Unemployment Insurance Claim File", ESDC PPU 150. You have the right to access your personal information. Instructions
for obtaining your personal information are provided in the Info Source, a copy of which is located in all Canada Employment Centres.
You should be aware that the information you provide may be subject to verification and that there are penalties for knowingly making false or misleading statements.
You should also be aware that your personal information may be used and/or disclosed under certain conditions as listed in the above-noted Personal Information Banks, in
accordance with the provisions of the Privacy Act and the Unemployment Insurance Act.

G - DECLARATION AND SIGNATURE

I declare that the information and answers given by me to the questions on this application are true to the best of my knowledge. I understand that this information will be used to
determine my eligibility for Unemployment Insurance Benefits and/or to obtain Employment services.

Year Month Day

SIGNATURE

This form must be signed by you. If you are unable to sign due to incapacity, your representative must sign his/her name.
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