Employer's Appeal to Referee

Employer's Appeal to Referee

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

Please refer to An Employer'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.
Date of Administrator's Decision or Mail Date of Charge Notice*

MonthDayYear
Enter the date located at the top of the Adjudications letter you received.
Form Number*
Docket Number*
Enter the 6-digit or 8-digit number at the top right corner of your hearing notice or Adjudications decision letter.
Please describe the document you are appealing. *

Employer Information
Employer Registration or Identification Number*
Enter the 10 digits of your Employer Registration or Identification Number.
Employer Name*
Employer Address*

Street Address

Street Address Line 2

StateCity/Town

Postal / Zip Code
Contact Name*
Contact Title*
Employer Phone Number*
Please enter a valid phone number.

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

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

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Other Parties - Claimants
Did the Adjudicator's decision involve a claimant?*

YesNo
You have indicated that the Adjudicator's decision involved a claimant. Please answer the questions below.
Claimant 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.
Claimant Social Security Number*
Enter the 9 digits of the claimant's Social Security Number (SSN).
Claimant Name

First NameLast Name
Claimant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer Questions
Please use the space below to enter the reason(s) why you disagree with the examiner's decision. *
Enter your response in the space above.
Was this appeal submitted within (1) 21 days of the decision date, or (2) 21 days of the mail date of the charge notice?*

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

Employer - Submit Your Appeal
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.

IN SUBMITTING THIS FORM, I HEREBY APPEAL FROM THE EXAMINER'S DECISION TO CHARGE MY MERIT RATING ACCOUNT AND APPLY FOR A HEARING.
Should be Empty:

Case Information