Claimant's Name**

(First, Middle, Last)

Claimant's Social Security Number**

-- (xxx-xx-xxxx)

Social Security Number

Date of Claim

(MM/DD/YYYY)

First day of disability

Date of Determination

(MM/DD/YYYY)

Date determination was made

Company Name

Name of employer

Company 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

Contact Name

(First, Middle, Last)

Contact at employer appealing this determination

Telephone

Contact number of the individual appealing this decision

(333)333-3333

Email Address

Electronic mailing address of the individual

yourname@abc.com

Reason for Appeal

Reason for employer appeal

(** indicates a required field)