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
Date
Date of Denial Notice
MonthDayYear
Date
Reason Provided for Denial
Basis for Appeal (Explain why you are appealing the denial)
Should be Empty: