Free WISHA NOTICE OF APPEAL FORM - Washington


File Size: 17.7 kB
Pages: 2
Date: October 30, 2008
File Format: PDF
State: Washington
Category: Government
Word Count: 401 Words, 2,918 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.biia.wa.gov/Forms/wishanoticeappeal.pdf

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WISHA NOTICE OF APPEAL FORM

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

WISHA NOTICE OF APPEAL
If you disagree with a decision of the Department of Labor & Industries concerning a WISHA citation and notice (CN) or Corrective Notice of Redetermination (CNR), 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 15 WORKING 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. Today's date: __________________ *required field

Citation and Notice No./Citation and Notice of Reconsideration No*______________________________________. I wish to appeal the CN/CNR of the Department of L & I dated:*____________________ Employer:*_______________________________________ Business Mailing Address*:__________________________________________________________________ City*: _______________________________State*: _____________ Zip*:_________ I disagree with the Department's determination because: ____________________________________________

_______________________________________________________________________________________________________ I believe the Board should give the employer the following relief: (vacate/modify)_________________________ I desire to have any proceedings held in: (City)______________________________ Do your employees belong to a Union*? ___Yes ____No

If so, please provide the name of union(s), business agent's name, address and phone number*:

INTERESTED EMPLOYEES OF THIS APPEAL HAVE BEEN NOTIFIED by*: ___Posting a copy of the notice of appeal at the work site. ________Date ___Providing copies of the notice of appeal to employee member so the safety committee. __________ Date

FAILURE TO COMPLETE THE ABOVE REQUIRED INFORMATION MAY REQUIRE THE BOARD TO SET ASIDE THE FINAL

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WISHA NOTICE OF APPEAL FORM

DECISION IT WILL ENTER IN YOUR APPEAL. I certify under penalty of perjury under the laws of the State of Washington, that the above information is true and correct to the best of my knowledge.* Dated this _____day of __________________, 20____ at ______________________, WA

Signature____________________________________________________________________ Phone: *(H) (W)

Please print name*:

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 a number where a message can be left. Also, please notify the Board if you have a change of address.

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