Employer Protest of Benefits Charge

Employer Protest of Benefit Charge
	Please complete all fields below and complete the Refusal of Work Questionnaire if appropriate, then click "Submit". You will receive a confirmation number which you should retain for your records. All protests will be addressed in the order in which they are received. Please do not submit duplicate requests for the same employee.

Company Name:

Employer Registration Number (ERN):

(ERN: (10 Digits. Ex: 0012345678))

Company Contact Person:

Contact Person's Title:

Telephone Number:

(Ex: 401-999-9999)

E-mail Address:

Employee's First Name:

Employee's Last Name:

Last 4 digits of employee's Social Security Number:

Reason For Protest:

Monthly Charge Statement Month/Year Protested:

Employee's Last Day of Work:

Reason Description:

"I certify under penalties of perjury that I am an authorized representative of the employer and that the information provided in this request for reconsideration of charges is true and correct to the best of my knowledge."