Unemployment Quote Submittal

Member Name (SU/District):*

Applicant Name:*

Applicant Title:*

Applicant Phone #:*

Applicant Email:*

There are two components needed to obtain a quote.

Please forward any additional documentation (if available).

Estimated taxable wages for the year you wish to join.*

This is defined as the first $8,000 in wages per employee (not FTE).

Do you have three complete fiscal years as well as the current year claims activity from the Vermont Department of Labor?*

Yes No

Please upload the information here.*

No File Chosen

File uploads may not work on some mobile devices.

Date:*

mm/dd/yyyy