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Appealing Party   Claimant Employer
Referee Case # (8 digits): 
Date of Referee Decision: 
Claimant Information (If Applicable)
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Employer Information (If Applicable)
Employer Registration Number: -  - 
Employer Name:
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Employer Email:
Employer Agent Information (If Applicable)
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I disagree with the Referee's decision for the following reason(s):

If this appeal is not transmitted within 15 days of the decision date, please explain why: 

IMPORTANT:
IN SUBMITTING THIS FORM, I HEREBY APPEAL THE REFEREE'S DECISION TO THE BOARD OF REVIEW.

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State of Rhode Island and Providence Plantations Seal Rhode Island Board of Review
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