Claimant Appeal Of Benefit Determination
Instructions:
Please fill out all of the required fields to file an appeal for your Unemployment or Temporary Disability Insurance determination. All fields marked
*
need to be filled in.
Claimant (Customer) Information:
First Name:
*
Last Name:
*
Social Security Number (no dashes):
*
Address 1:
*
Address 2:
City:
*
State:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
*
A confirmation of your online appeal application will be sent to the email address you enter here:
Email
*
Re-enter Email
*
(Please enter the same email address twice to confirm that the email address is correct)
Home Phone Number (no dashes):
Mobile Phone Number (no dashes):
Do you require an interpreter?
NO
YES
If YES, what language?
Please enter the information about the claim you are appealing, using the information on your determination letter.
An example of this determination letter is shown below.
Program Code:
*
10
11
12
20
21
22
23
30
31
40
41
42
43
45
50
51
60
61
80
81
83
88
Date of Claim [mm/dd/yyyy]:
*
Date of Determination (Date of Mailing) [mm/dd/yyyy]:
*
Date YOU Received Determination Letter [mm/dd/yyyy]:
*
Employer Name:
In the box below, for each determination (with the same date of mailing), please explain why you are disputing the determination.
*
VALIDATION TEXT:
Enter case-sensitive Validation Text here WITHOUT spaces. *
By clicking the submission button below, you are filing your appeal and certifying that the information contained in this appeal is true and correct to the best of your knowledge. You will receive a reference number to the email address you provide above when your appeal is filed. Keep a copy of that number for future reference.
Click here to submit your Appeal: