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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 Email:

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 Email:

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.

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State of Rhode Island and Providence Plantations Seal Rhode Island Board of Review
Center General Complex, 41 West Road, Hazard Bldg. #74, 1st Floor
Cranston, RI 02920
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