- Government of Bermuda

Bermuda Government Unemployment Benefits Application

Mandatory Medical Quarantine Benefits

Ensure you save link to this form https://uba.gov.bm/Form/FormQ/313ef284-8ae6-4a17-817d-94e7b2f0a729 in case you want to return back to it. DO NOT SHARE THIS LINK WITH ANY ONE AS IT INCLUDES YOUR PERSONAL DATA AND IT IS UNIQUE TO YOU.

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1. Employee Information

Social Insurance Number If you do not have this number on hand, please contact your employer or the Department of Social Insurance at 294-9242.

First Name

Middle Name

Last Name

Date of Birth M/DD/YYYY

Mailing Address

Parish

Postal Code

Home Phone Number

Cell Phone Number

Work Phone Number

Email Address

2. Status

Please select one of the following:

Please refer to section 8 and upload required documents:

Only one of the following documents is required):

Copy of Passport Information Page and Registered Bermudian Stamp
Copy of Voter’s Identification Card

Copy of Official Spousal Letter from the Department of Immigration

Copy of Permanent Resident Certificate

Copy of Official Work Permit Card issued by the Department of Immigration

3. Employment Status

Full-time employment (more than 15 hours per week)

Self employed

Your status

Are you able to work remotely?

Start of quarantine

Job Title

4. Employer’s/Self-Employment Details

CompanyName

Primary Contact

Employer Contact Number

Company Address

Postal Code

Nature Of Business

Employer Cell Phone Number

Work Phone Number

Email Address Please check for accuracy

5. Other Benefits

Are you on Financial Assistance or Supplementary Unemployment Benefit?:

Have you received unemployment benefits during COVID-19?

6. Payment Details

Please indicate how you are ordinarily paid

Dollar Amount Gross wage, including tips and benefits

If other, please specify

7. Banking Information

Bank Name

Account Type

Account Holder Name

Account Number (no spaces)
Note: You need to select bank name first.

*The applicant must be listed as an account holder on the account provided. The bank account details should match the account ordinarily used for payroll.

Have you worked previously for Government or a Quango

I authorize Government of Bermuda to verify the information provided on this form (1) to confirm my identity (2) to augment and update currently held information; (3) to provide me with accurate payment; (4) to satisfy information requests; and (5) to meet legal and regulatory requirements.

8. Required Supporting Documents

Please upload the following documentation to support your application. Failure to provide the information requested may result in significant processing delays and/or denial of your application.

SECTION 1 STATUS VERIFICATION

Only one of the following documents is required):

Copy of Passport Information Page and Registered Bermudian Stamp
Copy of Voter’s Identification Card

Copy of Official Spousal Letter from the Department of Immigration

Copy of Permanent Resident Certificate

Copy of Official Work Permit Card issued by the Department of Immigration

SECTION 2 VERIFICATION OF MANDATORY MEDICAL QUARANTINE (Upload file if applicable)

Letter from medical practitioner confirming mandatory quarantine

SECTION 3 SELF-EMPLOYMENT (Upload file if applicable)

Evidence of payroll tax submissions for two quarters

SECTION 4 VERIFICATION OF BANKING DETAILS (Upload file)

Copy of bank account statement to verify name, address and account number.

TERMS OF AGREEMENT

I certify that the information in this application is true and correct to the best of my knowledge. I confirm that I am not receiving Financial Assistance benefits. I understand the information requirements, conditions and terms of this benefit and agree to provide any supporting documentation that the Government of Bermuda may require. I understand that if I knowingly provide untrue, false, misleading or inaccurate information then I will be ineligible for the unemployment benefit, any benefit granted to me may be reversed, and I will be responsible for any and all repayment and may be subject to prosecution. I agree to provide my personal information in order for the Department of Workforce Development to determine my eligibility for an unemployment benefit to provide Covid-19 relief. I understand that the information shared will only be used for the purpose stated above.