If your situation is 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by completing Section 1, which requires your personal information. Ensure you select whether you are an employee, former employee, or dependent.
3. In Section 2, describe your request for review or appeal in detail. Be as specific as possible about the situation that led to your appeal.
4. Sign and date Section 3 to confirm the accuracy of the information provided. Keep a copy of this completed form for your records.
5. If applicable, complete Sections 4 through 6 for employer responses and ensure they are signed by a reviewer who did not participate in the initial decision-making process.
6. Finally, submit the completed form to your employer’s payroll or benefits office within the specified deadlines.

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