Free Industrial Insurance Notice of Appeal - Washington

Industrial Insurance Notice of Appeal

This form is intended to be printed, completed and mailed through the U.S. Postal Service. Forms or replications of forms returned by e-mail will not be accepted for processing.

Board of Industrial Insurance Appeals PO Box 42401 Olympia, WA 98504-2401

NOTICE OF APPEAL
Public Disclosure-Please note that information provided may be subject to pubic disclosure under RCW 42.56 If you disagree with a decision of the Department of Labor and Industries concerning a workers compensation claim, this form can be used to file an appeal of that decision. You must file the appeal with the Board of Industrial Insurance Appeals, WITHIN 60 DAYS of the date you received the Departments decision. The appeal can be filed with the Board personally or by mail at the above address. *indicates required information. Today's date:________________: Appeal filed by __Claimant __Beneficiary __Claimant's Physician __Employer Claimant's Name* ____________________ ______________________________________ L&I Claim No*: _______________ Date of L&I Decision*: _______ [copy attached]

Date of Injury/Occupational Disease: _________. City where injury/Occupational Disease occurred:_____ ___________ What are you asking for*:

Name of employer at time of injury*:

Business Mailing address of employer (main office) Address*:__________________________________________________________ City*: State*: Zip*:

http://www.biia.wa.gov/iinoteofappeal.htm (1 of 2) [10/30/08 3:47:43 PM]

Industrial Insurance Notice of Appeal

I desire to have any proceedings held in: (City) ____________________________________ (Signature of Preparer*) Name*: (Please Print)

Phone*: (H) Social Security No:

(W)

Address*: ______________________________________________________

City*____________________________________________State:_______Zip:________ It is important that the Board be able to reach you concerning your appeal. If you do not have a phone, please provide the number of a friend/relative where the Board can leave a message. Also, please notify the Board if you change your address.

http://www.biia.wa.gov/iinoteofappeal.htm (2 of 2) [10/30/08 3:47:43 PM]