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Department of Workforce Services EMPLOYMENT TERMINATION

DWS 631 Form

The purpose of this form is to prove that you have been separated from your employer or have had your hours reduced in order to maintain your insurance.

If needed, please download a blank template attached below and fill out your information, before sending the form to our office to be signed. To ensure that your request will not be delayed, please follow the appropriate template below when filling out your form.

631 DWS Blank Form
631 DWS Template for Student
631 DWS Template for Staff/Admin

We need a Signed Release form in conjunction with your request.

You can submit this completed form and signed release to our office. Once we have completed the form, we can fax it directly to the Department of Workforce Services for you. We will then send a scanned copy of the completed form to your email address.


  • Please do not submit your information using the template.
  • When submitting the form to our office, please either bring the form in person, scan and email the form, or fax it to the number below. We cannot accept a cell phone image of this form.
  • For security purposes, DO NOT include your SSN (DWS will be able to locate your file with your case name and number).
  • Requests are processed in the order received; multiple requests may result in additional delays.

Employment Verification Hub

2024 WSC
Open: Mon-Fri 8am-5pm
Email us:
Or leave a message: 801-422-0817
Fax: 801-422-0640