Employer 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.
Company (Employer) Information:
Company Name: *
FEIN (no dashes): *  
Address 1: *
Address 2:
City: *
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)
Office Phone Number (no dashes):
Mobile Phone Number (no dashes):
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]: *
   
Employee Social Security Number (no dashes): *
   
Employee First Name: *
   
Employee Last 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: