Board of Review for Unemployment and Temporary Disability Insurance Appeals of Referee Decisions for
Unemployment Insurance and Temporary Disability Insurance


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* Appealing Party:
Referee Appeal #:
(8 digits)
Date of Referee Decision:
Claimant Information
* Claimant Social Security Number: - -
* Claimant Name:
Claimant Street:
Claimant City:
Claimant State: Zip:
Claimant Telephone Number: () -
Claimant Email:
Claimant Attorney Information (If Applicable)
Claimant Attorney Name:
Claimant Attorney Street:
Claimant Attorney City:
Claimant Attorney State: Zip:
Employer Information (If Applicable)
Employer Name:
Employer Contact Person:
Employer Street:
Employer City:
Employer State: Zip:
Employer Telephone Number: () -
Employer Email:
Employer Agent Information
Employer Agent Name:
Employer Agent Street:
Employer Agent City:
Employer Agent State: Zip:
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 it is late:
FILE APPEAL:
By submitting this form, I hereby appeal the Referee’s decision.
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Board of Review, 41 West Road, Hazard Building #74, 1st Floor, Cranston, RI 02920 | Phone: (401) 462-9400 | Fax: (401) 462-9401  | Email: DLT.BORinfo@dlt.ri.gov

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