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
Crime Victim NOTICE OF APPEAL
If you disagree with a decision of the Department of Labor and Industries concerning a crime victim's 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 90 DAYS of the date you received the Department's decision. The appeal can be filed with the Board by mail at the above address.
*indicates required field
Today's date: _______________ Crime Victim Claim No: * ________________ Appeal filed by: * __Claimant __Beneficiary __ Guardian __Estate of
Claimant's Name:*First ___________________ Middle Initial __ last: * _________________________ Address: * _________________________________________________________________________ City: * __________________________________State: *__________________ Zip:* _____________ Work/Home Telephone: * _____________________ Contact E-mail: __________________________
I wish to appeal the decision of the Dept of Labor & Industries dated: _________________
The situation arose on (Date) _____________, at (Location) ___________________________________ What are you asking for? ___________________________________________________________________
I desire to have any proceedings held in: (City) _____________________________________________ (Signature) *_________________________________________________________________________ Name: (Please Print) * _________________________________________________________________
It is important that we 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 us if you change your address.