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- Click ‘Get Form’ to open it in the editor.
- Begin by completing Section 1, where you will provide your personal information. Select whether you are an employee, former employee, applicant, or dependent.
- In Section 2, describe your request for review or appeal. Be as detailed as possible about the situation that led to your appeal.
- Sign and date Section 3 to confirm that the information provided is accurate. Keep a copy of this completed form for your records.
- If applicable, complete Sections 4 through 6 for employer responses regarding your request. Ensure all required fields are filled out accurately.
- For appeals to the SEBB Appeals Unit, complete Section 7 after receiving the employer's decision. Attach any additional documentation if necessary.
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