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:		Fraudulent Charges – employee never unemployed (ID Theft) Voluntary Quit Without Good Cause Reasonable Assurance Refusal Of Work Valid Termination For Cause
Monthly Charge Statement Month/Year Protested:		December 2023 November 2023 October 2023 September 2023 August 2023 July 2023 June 2023 May 2023 April 2023 March 2023 February 2023 January 2023
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."