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Appealing Party   Claimant Employer
Referee Case # (8 digits): 
Date of Referee Decision: 
Claimant Information (If Applicable)
Claimant Social Security Number: -  - 
Claimant Name:
Street:
City:
State: Zip Code: 
Telephone Number: ()  - 
Claimant Agent Information (If Applicable)
Claimant Agent Name:
Street:
City:
State: Zip Code: 
Employer Information (If Applicable)
Employer Registration Number: -  - 
Employer Name:
Contact Person:
Street:
City:
State: Zip Code: 
Telephone Number: ()  - 
Employer Agent Information (If Applicable)
Employer Agent Name:
Street:
City:
State: Zip Code: 
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.

Please print a copy of this form, or write down the date and time. It may be used to verify submittal of appeal.
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Email: BORinfo@dlt.state.ri.us
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State of Rhode Island and Providence Plantations Seal Rhode Island Board of Review
275 Westminster St., Providence, R.I. 02903-3434
Phone (401) 222-3533
Fax    (401) 222-3514
email BOR@dlt.state.ri.us