Department of Labor and Workforce Development | Complaint (Appeal)

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Complaint (Appeal) - Private Plan Benefits

Docket No. ___________________

Claimant:	Employer:
Address:
Address:
	Type of Work Performed:
Telephone No:	Date disability started:
	Date disability ended:

NOTE: YOU MUST STATE SPECIFICALLY AND IN DETAIL THE REASON FOR YOUR COMPLAINT.
I hereby appeal the decision of with respect to my claim for temporary disability benefits under the above employer's Private Plan for the following reasons:
Date of Appeal
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.	Name: Address:

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