Claimant's Appeal to Referee

Claimant's Appeal to Referee

State of Connecticut Department of Labor, Employment Security Appeals Division
NOTES

Please refer to A Claimant's Guide to the Appeals Process for more information about the unemployment compensation appeals process.

"*" indicates a required field.
Case Information
Appellant:
Do not attempt to fill in this field. For office use only.
Mailing Date of the Decision Letter:*

MonthDayYear
Enter the date located at the top of the Adjudications decision letter.
Decision ID or Docket Number*
Enter the 6-digit or 8-digit number at the top right corner of your hearing notice or Adjudications decision letter.

Claimant Information
Claimant Social Security Number*
Enter the 9 digits of your Social Security Number (SSN).
Claimant Name*

First NameLast Name
Claimant Address*

Street Address

Street Address Line 2

StateTown/City

Zip Code
Claimant Phone Number*
Please enter a valid phone number.

Other Parties - Claimant Agents
Do you have an attorney, advocate, or agent working with you on this appeal?*

YesNo
You have indicated that you have an attorney, advocate, or agent working with you on this appeal. Will this attorney, advocate, or agent be submitting this appeal on your behalf?*

Yes, an attorney, advocate, or agent will be submitting this appeal on my behalf.No, I have an attorney, advocate, or agent working with me on this appeal, but I will be submitting it myself.
You have indicated that you have an attorney, advocate, or agent working with you to submit this appeal to the Referee on your behalf. Please have your attorney, advocate, or agent answer the questions below.
Claimant Agent Information
Claimant Agent Name*

First NameLast Name
Claimant Agent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Other Parties - Employers
Did the Adjudicator's decision involve an employer?*

YesNo
You have indicated that the Adjudiucator's decision involved an employer. Please answer the questions below.
Employer Information
Which of the following issues pertain(s) to this appeal? *
Select an option from the menu above.
Please explain this issue in more detail. *
Enter your response in the space above.
Employer Registration or Identification Number*
Enter the 10 digits of the employer's Employer Registration or Identification Number.
Employer Name*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Claimant Questions
Use the space below to enter the reason(s) why you disagree with the examiner's decision. If you received more than one decision, please also specify which decision(s) you are appealing. *
Enter your response in the space above.
Was this appeal submitted within 21 days of the decision date?*

YesNo
You have indicated that this appeal was not submitted within 21 days of the decision. Please use the space below to explain why. *
Enter your response in the space above.

Claimant - Continue to File
Please check the box below to acknowledge that you understand that you must continue to file claims pending a decision by the Referee on your appeal. If you fail to file a claim each week, as directed, no benefits can be paid for those weeks, irrespective of the decision of the Referee.*

I understand the above.
IMPORTANT

PLEASE BE SURE TO PRINT A COPY OF THE DATA CONFIRMATION PAGE THAT WILL DISPLAY AFTER YOU SUBMIT THIS FORM. KEEP THIS COPY FOR YOUR RECORDS. YOUR COPY OF THE DATA CONFIRMATION PAGE VERIFIES THAT YOUR APPEAL HAS BEEN FILED AND RECEIVED FOR PROCESSING BY THE UNEMPLOYMENT DEPARTMENT.

IN SUBMITTING THIS FORM, I HEREBY APPEAL FROM THE UNEMPLOYMENT DEPARTMENT'S DECISION DENYING BENEFITS AND APPLY FOR A HEARING.
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Case Information