Claimant Name**

Name of the individual wishing to appeal a claim for private plan benefits

Claimant's Social Security Number**

-- (xxx-xx-xxxx)

Address:**

(Street)

(Address Line 2)

AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI WA WA WV WI WY (City, State, Zip as nnnnn-nnnn or nnnnn)

Address of the individual

Home Telephone No:**

Contact number of the individual

(333)333-3333

Employer Name**

Name of Employer

Employer Address**

(Street)

(Address Line 2)

AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI WA WA WV WI WY (City, State, Zip as nnnnn-nnnn or nnnnn)

Address of the employer

Insurance Carrier Name**

Name of the Insurance Carrier

Date Family Leave Started:**

(MM/DD/YYYY)

Date Family Leave Ended:

(MM/DD/YYYY)

NOTE: YOU MUST STATE SPECIFICALLY AND IN DETAIL THE REASON FOR YOUR COMPLAINT.

I hereby appeal the decision of determination made on**

(MM/DD/YYYY)

Date the determination was made

with respect to my claim for family leave benefits under the above employer's Private Plan for the following reasons:**

(** indicates a required field)