Free Industrial Insurance Notice of Appeal - Washington

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. You can also electronically file by going to our web site at http://www.biia.wa.gov and clicking on the e-Filing icon.

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

ASSESSMENT NOTICE OF APPEAL
(Not for Workers' Compensation Appeals)
If you disagree with a decision of the Department of Labor and Industries concerning the assessment of industrial insurance taxes, or the classification of workers and the rate of taxes assessed, 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 30 DAYS of the date you received the Department's decision. The appeal can be filed with the Board personally or by mail at the above address. *indicates required field

Today's date: _______________ I wish to appeal the decision of the Dept of Labor & Industries dated: _________________ Firm No.* _______________________ Firm Name:* ________________________________________________________________________ Business mailing address (Main Office) Street Address (or PO Box): * ___________________________________________________________________________________ _________________________________ _______________________________
City: State:
[copy attached]

________________
Zip:

Please state what you are asking for: _____________________________________________________ ___________________________________________________________________________________ I desire to have any proceedings held in: (City) _____________________________________________ (Signature)*_________________________________________________________________________ Name: (Please Print) First:* ___________________________ Last:*____________________________ Work/Home Telephone:* _____________________ Contact E-mail: ___________________________

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 we can leave a message. Also, please notify the us if you change your address.

6.15.09