Claimant Appeal Of Benefit Determination

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:
State: *
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?
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.
determination letter sample
Program Code: *
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. *
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: