Workers’ Compensation Claim Denial Appeal Form

Workers’ Compensation Claim Denial Appeal Form
Submit your appeal for a denied workers’ compensation claim. Please provide complete and accurate information.
Claimant Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Employer Name
Claim Number
Date of Original Claim Submission
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Denial Notice
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason Provided for Denial
Basis for Appeal (Explain why you are appealing the denial)
Should be Empty: