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| Employer: |
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| Claimant: |
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| Telephone Number: |
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| Address1: |
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| Address2: |
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| Date Family Leave Started: |
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| Date Family Leave Ended: |
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| NOTE: YOU MUST STATE SPECIFICALLY AND IN DETAIL THE REASON FOR YOUR COMPLAINT. |
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I hereby appeal the decision of with respect to my claim for family leave benefits under the above employer's Private Plan for the following reasons:
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| Date of Appeal: |
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| NOTE: You do not have to be represented by an attorney. If an attorney or non-attorney is representing you, please indicate his or her name and address in the space to the right. |
| Attorney: |
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| Address1: |
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| Address2: |
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| City/State/Zip: |
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