Requesting Form E301/PD U1 via the internet

To apply for unemployment benefit abroad

The purpose of this form
This form enables you to request Form E301/PD U1 from the UWV.
Form E301/PD U1 states the periods that you have been insured as
an employee in the Netherlands. You need this form to apply for
unemployment benefit abroad. You can send this application within
4 weeks of the end of your employment contract.
What you should send with the application
Send as much proof of your employment history with your
application as possible (see Question 2.4). Usually we can process
applications within 2 weeks. It will take longer to process your
application without proof (up to a maximum of 6 weeks).
Where to send the form
After completing the form, email it together with your proof (see
Question 2.4) to uwv.verdragen@uwv.nl.
If you are unable to email the documents, you can print the
form and send it with any proof you have to the following
address:
UWV
Afdeling WW Internationaal
Postbus 124
7550 AC HENGELO
The Netherlands
After you have sent this form
After you have sent this form to the UWV, Form E301/PD U1
will be sent to your home address within around 6 to 8 weeks.
More information
You will find more information at uwv.nl/internationaal. You
can also call the UWV Employees Telephone Desk on
0900 898 92 94.
If you are abroad, please call +31 88 898 20 01. The UWV
assistant will talk to you in Dutch.
Please keep your citizen service number to hand when you
call, so that we can provide you with the best possible service.

What am I signing for

Declaration of intent I have provided correct and complete information about me and my situation on this form.
1.1 Surname 1 Personal details
If you use the last name of your partner, please also fill out your birth name (maiden name).
1.1 Surname
      Male Female

1.2 First name(s)      

1.3 Address where Form E301/PD U1 Street and house number      
should be sent to
Postcode and place            

Country      

1.4 Citizen service number      

1.5 Date of birth      

1.6 Place of birth      

1.7 Nationality      

1.8 Telephone number      

1.9 E-mail address      

2 About your situation

2.1 Have you received Form E301/PD U1 Yes

before? No

2.2 In which country are you applying for      

unemployment benefit?
Use Appendix 1 Statement of employment history to complete this question.
2.3 How long did you work in the
Netherlands for?       year(s)

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2.4 Send as much proof of all the
employment relationships that you
had in this period as possible.
3 Last employer
3.1 Company name
3.2 Address
3.3 Profession or type of activities
3.4 Period you worked there
4 Reason your last employment relationship ended
4.1 Why was the employment ended?
4.2 Was the employment contract ended
by the subdistrict court?
4.3 Was the employment contract ended
via a UWV dismissal permit?
4.4 Was the employment contract ended
via a termination or settlement
agreement?
5 Other employers
5.1 Have you had more than 1 employer
in your employment history
according to Appendix 1 State of
employment history per country?
6 Any additional information
6.1 Please provide any additional
information you wish to send here.
7 Signature
Date and signature
Indicate which form of proof you are sending.
Copy of your employment contract.
Copy of your salary slips from the last past 3 months.
Copy of your employer's statement(s) (period(s) worked and reason for leaving).
Copy of your resignation letter (if applicable).
Copy of the subdistrict court's decision to terminate the employment relationship (if
applicable).
Copy of the UWV dismissal permit and notice of dismissal (if applicable).
Copy of termination/settlement agreement (if applicable). This must have been signed by
both parties.
     
Street and house number      
Postcode and place            
Country      
     
From       to and including      
Employee resigned.
Dismissed by employer.
Employment contract ended.
Employment contract was ended by mutual agreement.
Summary dismissal.
Dismissed for business reasons.
Activities/secondment activities ended.
Other reason      
No
YesEnclose a copy of the decision.
No
YesEnclose a copy of the dismissal permit and notice of dismissal.
No
YesEnclose a copy of the termination/settlement agreement. This must have been
signed by both parties.
NoContinue to Question 6.1.
YesIf you had more than 2 employment relationships in that period, enter the 3rd and
other other employers in Appendix 2 Other employers. If there is not enough room,
you can send a separate sheet of paper.
Company name      
Address      
Postcode and place            
Country      
Period you worked there
From       to and including      
     
     
2 of 6
 Appendix 2 State of employment history per country
In columns 2 and 5

Country in which you are applying The employment history that we need
for unemployment benefit

Belgium provide your past 3 years' employment history in the Netherlands

Bulgaria provide your full employment history in the Netherlands

Cyprus provide your past 3 years' employment history in the Netherlands

Denmark provide your past 3 years' employment history in the Netherlands

Germany provide your past 5 years' employment history in the Netherlands

Estonia provide your full employment history in the Netherlands

Finland provide your full employment history in the Netherlands

France provide your past 3 years' employment history in the Netherlands

Greece provide your past 3 years' employment history in the Netherlands

Hungary provide your past 4 years' employment history in the Netherlands

Ireland provide your past 3 years' employment history in the Netherlands

Iceland provide your past 2 years' employment history in the Netherlands

Italy provide your past 2 years' employment history in the Netherlands

Croatia provide your full employment history in the Netherlands

Latvia provide your full employment history in the Netherlands

Liechtenstein provide your past 2 years' employment history in the Netherlands

Luxembourg provide your past year's employment history in the Netherlands

Malta provide your full employment history in the Netherlands

Norway provide your past 3 years' employment history in the Netherlands

Austria provide your full employment history in the Netherlands

Poland provide your full employment history in the Netherlands

Portugal provide your past 3 years' employment history in the Netherlands

Romania provide your full employment history in the Netherlands

Slovenia provide your full employment history in the Netherlands

Slovakia provide your past 4 years' employment history in the Netherlands

Spain provide your past 6 years' employment history in the Netherlands

Czech Republic provide your past 3 years' employment history in the Netherlands

United Kingdom provide your past 3 years' employment history in the Netherlands

Sweden provide your past 8 years' employment history in the Netherlands

Switzerland provide your past 2 years' employment history in the Netherlands

AG140 15514 09-17 W 3 of 6

 Appendix 2 Other employers
Continued in column 5

3 Company name      

Address Street and house number      

Postcode and place            

Country      

Period you worked there From       To      

4 Company name      

Address Street and house number      

Postcode and place            

Country      

Period you worked there From       To      

5 Company name      

Address Street and house number      

Postcode and place            

Country      

Period you worked there From       To      

6 Company name      

Address Street and house number      

Postcode and place            

Country      

Period you worked there From       To      

7 Company name      

Address Street and house number      

Postcode and place            

Country      

Period you worked there From       To      

8 Company name      

Address Street and house number      

Postcode and place            

Country      

Period you worked there From       To      

AG140 15514 09-17 W 5 of 6

9 Company name      

Address Street and house number      

Postcode and place            

Country      

Period you worked there From       To      

10 Company name      

Address Street and house number      

Postcode and place            

Country      

Period you worked there From       To      

11 Company name      

Address Street and house number      

Postcode and place            

Country      
Period you worked there From       To      

12 Company name      

Address Street and house number      

Postcode and place            

Country      

Period you worked there From       To      

AG140 15514 09-17 W 6 of 6