Workers Rights Clinic Intake Form
We are a free clinic, staffed by Michigan Law students, that is focused on workers' rights, primarily by addressing their issues with Unemployment Insurance claims. We provide advocacy, advice and assistance to Michigan workers.

Please fill out the below form to request assistance with an unemployment insurance claim.
This is an intake form for individuals who have applied, or tried to apply, for unemployment benefits. Unfortunately, we cannot assist individuals who have not yet applied.

One of our intake staff will call you to get more information on your claim, and our director will then assess if we are able to take on your case. Please be aware that it may take several days to a few weeks before you hear from us due to current demand. Also note that from time to time we reach maximum case capacity and may not be able to provide representation.

For more information, see our website. https://www.law.umich.edu/clinical/workersrights/Pages/default.aspx
The below information is to create a record for you in our system. All the information you provide will be internal to the Clinic and will be kept confidential.
First name
Last name
Phone number
Best time to reach you on a weekday?
Email
Separating employer (the employer from whom you are claiming benefits, or if you applied for PUA, please list your last employer)
Your former job title(s) with the employer listed above.
Address where you currently live and receive mail.
Last four digits of your social security number
Birth date
MM
/
DD
/
YYYY
What county do you live in?
Marital Status
Clear selection
Gender
Clear selection
Hispanic Ethnicity
Clear selection
Race
Clear selection
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