Employer's Appeal to the Superior Court

Employer's Appeal to the Superior Court

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

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

"*" indicates a required field.
Case Information
Party Filing Motion*
Do not attempt to fill in this field. For office use only.
Date of Board of Review Decision: (i.e., the date located at the top of the Board of Review decision letter)*

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

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*

Area CodePhone 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 motion to reopen the Board of Review's decision on your behalf. Please have your attorney or agent answer the questions below.
Employer Agent Information
Employer Agent Name*

First NameLast Name
Employer Agent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Other Parties - Claimants
Did the Board of Review's decision involve a claimant?*

YesNo
You have indicated that the Board of Review's decision involved a claimant. Please answer the questions below.
Claimant Information
Which of the following issues pertains to this appeal?*
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 Board of Review's decision.*
Enter your response in the space above.
Was this appeal submitted within 30 days of the decision date?*

YesNo
You have indicated that this appeal was not transmitted within 30 days of the decision date. Please use the space below to explain why.
Enter your response in the space above.

Employer - Submit Your Appeal
Please verify that you are human.*
For verification purposes, please trace the image presented:*
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 THE BOARD OF REVIEW'S DECISION TO THE SUPERIOR COURT.
Should be Empty:

Case Information