Rhode Island Board of Review with pictures
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.

Code Image - Please contact webmaster if you have problems seeing this image code  Refresh Refresh Image
Enter the code exactly as you see it in the image:
Powered by Web Wiz CAPTCHA version 4.02
Copyright ©2005-2011 Web Wiz Ltd.
..
Email: BORinfo@dlt.state.ri.us
Referee Hearings  |  Filing an Appeal  |  Search Past Cases | Contact Us |   Board of Review Home | DLT Home

State of Rhode Island and Providence Plantations Seal Rhode Island Board of Review
Center General Complex, 74 West Road, Hazard Bldg., 1st Floor
Cranston, RI 02920
Phone (401) 462-9400 | Fax (401) 462-9401
email BOR@dlt.ri.gov