Board of Appeals
Employer Appeal
Claimant ID
ClaimantID is Required
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Re Enter Claimant ID
ClaimantID dose not match
ClaimantID is Required
Case Number
Case Number is Required
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Employer Legal Business Name
Employer Legal Business Name is required
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Employer Representative Name
Employer Representative Name is required
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Employer Representative Email Address
Please enter valid email address
Employer Representative Phone Number
Employer Representative Phone Number is Required
State Employer ID
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Claimant First Name
Claimant First Name is required
Claimant Last Name
Claimant Last Name is required
Reason for Employer Appeal (Max: 3500 Characters)
If your address has changed, please enter below.
Comment is Required
Maximum characters: 3500
Optional:
Attach pertinent documents to be considered with your appeal.
Acceptable file types are:
.jpg .jpeg .png .pdf .doc .docx.
Max size:
4 MB
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