Employer Notification to Employees of the Availability of 
                         Unemployment Compensation 

Unemployment Insurance (UI) benefits are available to workers who are 
unemployed and who meet the requirements of state UI eligibility laws. You may 
file a UI claim in the first week that employment stops or work hours are reduced. 

For assistance or more information about filing a UI claim, 
call 1-844-224-5818 or visit www.jobs4tn.gov. 

You will need to provide the state UI agency with the following information in order 
for the state to process your claim: 

1. Your full legal name;
2. Your Social Security Number; and
3. Your authorization to work (if you are not a US Citizen or

resident. To file a UI claim by phone call: (844) 224-5818 

To file a UI claim online, visit: www.jobs4tn.gov 

If you have questions about the status of your UI claim, you can call the state UI 
agency at  1-844-224-5818 or email lwd.support@tn.gov.  

LB-0489 (Rev. 0 -8 2020)                                                           RDA 0063

                                                        STATE OF TENNESSEE
                                        DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT 
                                        DIVISION OF EMPLOYMENT SECURITY

                                        SEPARATION NOTICE

1. Employee's  Name:  ________________________________________________________    2.  SSN:  _____________________
                     First               Middle Initial  Last
3. Last Employed: From: _______________ to _______________    Occupation: _____________________________________
                           (mm/dd/yyyy) (mm/dd/yyyy)
4. Where  was  work  performed?  _____________________________________________________________________________

5. Reason for Separation:  Lack of Work                      Discharge    Quit

If lack of work, indicate if layoff is: Permanent            Temporary - Recall Date
                                                                                     (mm/dd/yyyy)
If temporary, report any vacation pay that will be paid.    Week Ending Date _____________ Amount $ ______________
                                                                          (mm/dd/yyyy)
If layoff is indefinite vacation pay should not be reported.

6. Employee received:   Wages in Lieu of Notice              Severance Pay

In the amount of $ _________________ for period from _________________ to _________________
                                                          (mm/dd/yyyy)    (mm/dd/yyyy)
If other than lack of work, explain the circumstances of this separation:

Employer's Name:
                _________________________________________________________________________________________________________
Address where additional information may be obtained:                      Employer's Telephone Number:

                                                                          Employer's Email Address:

                                                             Number shown on State Quarterly Wage Report (LB-0851) and 
Employer's Account Number:                                   Premium Report (LB-0456)

I certify that the above worker has been separated from work and the information furnished hereon is true and correct.  
This report has been handed to or mailed to the worker.
Signature of Official or Representative of the Employer      Title of Person Signing                 Date Completed 
who has first-hand knowledge of the separation                                                       and Released to 
                                                                                                     Employee
_________________________________________________________    _______________________________________ ____________________ 
                                                                                                                 (mm/dd/yyyy)
                                                        NOTICE TO EMPLOYER
Within 24 hours of the time of separation, you are required by Rule 0800-09-01-.02 of the Tennessee Employment Security 
Law to provide the employee with this document, properly executed, giving the reasons for separation.  If you subsequently 
receive a time sensitive request for separation information for the same information please give complete information in 
your response.
                                                        NOTICE TO EMPLOYEE
YOU MAY BE INSTRUCTED TO MAIL OR FAX THE SEPARATION NOTICE TO TENNESSEE CLAIMS OPERATIONS IF YOU 
FILE A CLAIM FOR UNEMPLOYMENT INSURANCE BENEFITS.

LB-0489 (Rev. 08-2020)                                                                                           RDA 0063

                                          STATE OF TENNESSEE
                       DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT 
                                    DIVISION OF EMPLOYMENT SECURITY

                                          INSTRUCTIONS 
                                          SEPARATION NOTICE

Rule  0800-09-01-.02  of  the  Rules  and  Regulations  of  the  Tennessee  Employment  Security  Law,  requires  all 
employers to furnish each separated employee with a Separation Notice, LB-0489, within 24 hours of the 
employee's separation from employment.

Separation Notices do not have to be given to any employee who has been in your employ for less than a week 
or who will be recalled within seven days.

Separation Notices reduce the administrative costs of processing an unemployment insurance claim and helps 
make a more accurate determination of the claimant's eligibility for benefits.

Please complete the Separation Notice in its entirety.

Item 5

Check the appropriate block as to the reason the worker is separated.  If the separation was for any reason 
other  than  lack  of  work,  give  a  clear  explanation  for  the  separation  in  the  box  provided.    Please  indicate 
whether the separation is permanent or temporary, and, if temporary, when you expect to recall the worker.

Item 6
Wages in lieu of notice and severance pay affect UI

The Unemployment Insurance Accountability Act of 2012 denies unemployment insurance benefits to any 
claimant  who  is  receiving  or  has  received  wages  in  lieu  of  notice  equivalent  to  the  wages  he  could  have 
earned in that week had he been permitted to work during the period of notice. Wages in lieu of notice are 
wages paid under circumstances in which the employer did not give an advance notice of separation to the 
employee and are paid irrespective of the length of service of the employee.

UI benefits will also be denied to any claimant for any week in which he received a severance package that 
includes an equivalent amount of salary the employee would have received if he were working during that 
week.

Both the wages in lieu of notice and the severance provisions will not apply to claimants whose separating 
employer filed notice of a reduction in operations, in accordance with Tennessee Employment Security law, 
prior to July 1, 2012.

To obtain Separation Notice forms, please:

 Make copies of the form, or

 Visit our website tn.gov/workforce

LB-0489 (Rev. 08-2020)                                                        RDA 0063