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Employer Reporting Instructions
Part VII - Additional Communications About Service and Compensation Reports
Chapter 5: Form UI-41, Supplemental Report of Service or Compensation  
 
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Form UI-41 and UI-41a (Computer Generated)

Forms UI-41 PDF File Format and UI-41a, Supplemental Report of Service or Compensation, are used to obtain reports of compensation at a higher maximum than reported on your annual report. This information may allow your employee to receive additional Unemployment Insurance (UI) or Sickness Insurance (SI) benefits. This form is accepted as valid certification of service and compensation provided it is signed by the contact official or a designee.

The forms are is designed to obtain service and compensation information needed to determine eligibility for benefits under the RUIA. Complete the information for each item checked as follows:

Service Months Verify whether the employee worked or is otherwise entitled to service for the months checked.
Service Months and Compensation Year(s) Enter the amount of employee’s compensation up to the maximum shown for each month he or she worked or otherwise received compensation.
Rate of Pay for Last Day Worked in Calendar Year Enter the employee’s pay rate (per hour, day, month, etc.) for the last day worked in the year shown.
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