NOTICE OF APPEAL AND REQUEST FOR ADMINISTRATIVE HEARING

(“Disability Insurance Appeal”)

[CLAIMANT NAME], Appellant
v.
[INSURER/AGENCY NAME], Respondent

Effective Date: [DATE]
Jurisdiction: Washington State – Office of Administrative Hearings (“OAH”)
Governing Law: state_disability_law (see RCW 34.05.010 et seq.)

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block
XI. Certificate of Service

I. DOCUMENT HEADER

1. Parties.
   1.1 Appellant: [CLAIMANT NAME], residing at [ADDRESS] (“Claimant”).
   1.2 Respondent: [INSURER/AGENCY NAME], a [STATE] entity with its principal place of business at [ADDRESS] (“Respondent”).

2. Recitals.
   A. Claimant submitted a disability claim dated [DATE] under Policy/Program No. [NUMBER] (“Policy”).
   B. Respondent issued a written Denial or Termination of Benefits dated [DATE] (“Denial Letter”).
   C. Claimant timely files this Notice of Appeal pursuant to Washington Administrative Procedure Act, Wash. Rev. Code § 34.05.010 et seq., and any applicable Policy appeal provisions.

3. Consideration. Mutual promises herein constitute sufficient consideration.

II. DEFINITIONS

For ease of reference, the following terms shall have the meanings set forth below:

“Administrative Court” means the Washington Office of Administrative Hearings or other tribunal with statutory authority over this matter.

“Appeal Record” means the complete administrative record, including all pleadings, exhibits, medical evidence, vocational evaluations, and hearing transcripts.

“Benefit Amount” means the total past-due and future disability payments claimable under the Policy, not to exceed [SPECIFY DOLLAR CAP].

“Denial Letter” has the meaning assigned in Section I.2.B.

“Medical Evidence” means any treating or consulting provider records, diagnostic tests, functional assessments, and expert opinions offered to prove disability.

“Vocational Factors” means age, education, training, work history, transferable skills, and labor-market data relevant to employability under 20 C.F.R. § 404.1560-.1569a (incorporated by Policy reference).

[// GUIDANCE: Add or delete definitions to mirror the specific Policy and factual record.]

III. OPERATIVE PROVISIONS

1. Filing of Appeal.
   1.1 Claimant hereby appeals the Denial Letter in its entirety and requests a de-novo administrative hearing.
   1.2 This filing is within all contractual and statutory deadlines.

2. Issues Presented. The central issues are:
   (a) Whether Claimant meets the Policy’s definition of “Total Disability”;
   (b) Whether Respondent properly considered all Medical Evidence;
   (c) Whether Respondent properly evaluated Vocational Factors; and
   (d) Whether benefits should be reinstated retroactively and paid prospectively.

3. Requested Relief.
   (a) Immediate interlocutory order compelling provisional benefit payments pending final adjudication (injunctive relief – “benefit_payment”).
   (b) Reversal of Denial Letter;
   (c) Award of past-due benefits with interest;
   (d) Continuation of benefits so long as disability persists; and
   (e) Attorney fees and costs as allowed by law or Policy.

4. Evidence Submission.
   4.1 Medical Evidence. Claimant encloses or will timely supplement:
   • Treating physician narratives dated [DATES];
   • Objective test results (MRI, EMG, etc.);
   • Functional Capacity Evaluation dated [DATE].
   4.2 Vocational Evidence. Claimant encloses or will timely supplement:
   • Vocational expert report assessing inability to perform past relevant work;
   • Labor market survey.
   4.3 Respondent’s complete claim file is requested under RCW 48.18.290.

5. Hearing Request. Claimant requests an in-person/telephonic/video hearing, with the right to present testimony, cross-examine witnesses, and submit post-hearing briefs.

6. Deadlines.
   (a) Respondent shall file its Hearing Presentation within 20 days of service of this Notice.
   (b) The Administrative Court shall issue a Scheduling Order within 30 days.

7. Conditions Precedent. None other than timely filing of this Appeal.

IV. REPRESENTATIONS & WARRANTIES

1. Claimant represents that all factual statements herein and in supporting documents are true, correct, and complete to the best of Claimant’s knowledge.
2. Counsel for Claimant represents that this filing complies with all applicable Washington rules of professional conduct and administrative procedure.
3. These representations survive until final disposition of this matter.

V. COVENANTS & RESTRICTIONS

1. Cooperation. Each Party shall reasonably cooperate in discovery, exchange of medical authorizations, and scheduling of depositions or examinations.
2. Notice. A Party receiving new, material evidence shall notify the other Party within five (5) business days.
3. Compliance. Claimant agrees to attend any independent medical examination reasonably scheduled under the Policy, provided it is consistent with WAC 296-23-302.

VI. DEFAULT & REMEDIES

1. Events of Default.
   (a) Failure of Respondent to produce the complete claim file;
   (b) Failure of either Party to comply with discovery deadlines;
   (c) Non-payment of provisional benefits if ordered.
2. Cure Period. Ten (10) calendar days after written notice.
3. Remedies.
   (a) Motion to compel or preclude evidence;
   (b) Adverse inference instructions;
   (c) Monetary sanctions including attorney fees.

VII. RISK ALLOCATION

1. Indemnification. Not applicable—administrative benefit dispute only.
2. Limitation of Liability. Any monetary exposure of Respondent is capped at the Benefit Amount plus statutory interest.
3. Insurance. Each Party bears its own insurance obligations.
4. Force Majeure. Filing and hearing deadlines may be extended for force majeure events upon motion and good cause shown.

VIII. DISPUTE RESOLUTION

1. Governing Law. Washington State disability insurance statutes, regulations, and common law, supplemented by federal regulations incorporated by the Policy.
2. Forum Selection. Exclusive jurisdiction lies with OAH (administrative_court).
3. Arbitration. Not available or required.
4. Jury Waiver. Claims are subject to administrative adjudication; jury trial right is inapplicable.
5. Injunctive Relief. The Administrative Court retains authority to order provisional benefit payments to prevent irreparable harm.

IX. GENERAL PROVISIONS

1. Amendments & Waivers. Must be in writing and approved by the Administrative Court or by stipulation of the Parties.
2. Assignment. Neither Party may assign rights in this proceeding without written consent and Court approval.
3. Successors & Assigns. Binding upon the Parties and their lawful successors.
4. Severability. If any provision is invalid under applicable law, the remainder shall remain in force, and the invalid provision reformed to the minimum extent necessary.
5. Integration. This Notice of Appeal constitutes the entire appeal pleading; no prior statements modify its terms.
6. Counterparts. This document may be executed in one or more counterparts, including electronic signatures under RCW 19.360.020.

X. EXECUTION BLOCK

Attorney for Claimant (if any):

[ATTORNEY NAME], WSBA No. [######]
[LAW FIRM NAME]
[ADDRESS] • [PHONE] • [EMAIL]

[// GUIDANCE: Add notarization or witness blocks only if specifically required by OAH rule or Policy.]

XI. CERTIFICATE OF SERVICE

I certify that on [DATE], I served a true and correct copy of this Notice of Appeal and all attached exhibits on:

• Respondent at [ADDRESS / EMAIL / FAX]
• Office of Administrative Hearings at [ADDRESS / ELECTRONIC FILING PORTAL]

by ☐ U.S. Mail ☐ Hand Delivery ☐ Email ☐ E-Filing (check all that apply).

[NAME], [Title]

[// GUIDANCE:
1. Attach Denial Letter, medical records index, and vocational report as Exhibits A, B, and C.
2. Confirm the correct OAH filing address and method (e-file portal vs. mail).
3. Calendar the statutory deadline under the Policy and/or RCW 34.05.542 (commonly 30 days from receipt of the Denial Letter) to avoid jurisdictional dismissal.
4. Consider moving for an interim order of continued benefits if Claimant faces immediate financial hardship.
5. Customize limitation of liability language if Policy provides for additional penalties or attorney fee shifting.]