REQUEST FOR APPEAL / PETITION TO REOPEN

(Workers' Compensation Claim Dispute)

TABLE OF CONTENTS

1. Appeal Information
2. Claimant Information
3. Employer/Insurer Information
4. Decision Being Appealed
5. Grounds for Appeal
6. Relief Requested
7. Supporting Evidence
8. Claimant Certification
9. Filing Instructions and Deadlines
10. Service of Process

SECTION 1: APPEAL INFORMATION

DATE OF APPEAL: [DATE]

CLAIM/CASE NUMBER: [CLAIM NUMBER]

WCAB/BOARD CASE NUMBER (if assigned): [CASE NUMBER]

TYPE OF APPEAL:
☐ Appeal of Claim Denial
☐ Appeal of Benefit Determination
☐ Appeal of Utilization Review/Treatment Denial
☐ Request for Independent Medical Review (IMR)
☐ Petition to Reopen Claim
☐ Appeal of Administrative Decision
☐ Appeal of Hearing Officer/Judge Decision
☐ Other: [SPECIFY]

STATE/JURISDICTION: [STATE]

SECTION 2: CLAIMANT INFORMATION

2.1 Injured Worker

Full Legal Name: [FULL NAME]

Date of Birth: [DATE]

Social Security Number: [XXX-XX-XXXX]

Home Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE NUMBER]

Email: [EMAIL]

Preferred Language: [LANGUAGE]
☐ Interpreter needed for hearings

2.2 Attorney/Representative Information (if applicable)

☐ Claimant is self-represented (pro se)
☐ Claimant is represented by:

Attorney/Representative Name: [NAME]

Firm Name: [FIRM NAME]

State Bar Number: [NUMBER]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE NUMBER]

Fax: [FAX NUMBER]

Email: [EMAIL]

SECTION 3: EMPLOYER/INSURER INFORMATION

3.1 Employer

Employer Name: [EMPLOYER LEGAL NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE NUMBER]

3.2 Workers' Compensation Insurance Carrier

Carrier Name: [CARRIER NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Claims Examiner: [NAME]

Phone: [PHONE NUMBER]

Fax: [FAX NUMBER]

3.3 Defense Attorney (if known)

Name: [NAME]

Firm: [FIRM NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE NUMBER]

SECTION 4: DECISION BEING APPEALED

4.1 Original Claim Information

Date of Injury: [DATE]

Body Part(s) Injured: [LIST BODY PARTS]

Nature of Injury: [DESCRIBE INJURY]

Date Claim Filed: [DATE]

4.2 Decision/Determination Being Appealed

Date of Decision: [DATE]

Decision Made By:
☐ Claims Administrator/Insurance Carrier
☐ Utilization Review Organization
☐ Workers' Compensation Judge/Hearing Officer
☐ Workers' Compensation Appeals Board
☐ Other: [SPECIFY]

Type of Decision:
☐ Denial of entire claim
☐ Denial of specific benefits
☐ Denial of medical treatment
☐ Permanent disability rating determination
☐ Temporary disability benefit amount/duration
☐ Termination of benefits
☐ Apportionment determination
☐ Other: [SPECIFY]

4.3 Summary of Adverse Decision

The decision being appealed states:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

The decision was based on the following reasons (as stated in denial/decision):

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

SECTION 5: GROUNDS FOR APPEAL

5.1 Basis for Appeal

I/We appeal this decision on the following grounds:

☐ Factual Error
The decision is based on incorrect or incomplete facts.
Explanation:
____________________________________________________________________________

____________________________________________________________________________

☐ Legal Error
The decision misapplies workers' compensation law or regulations.
Explanation (cite specific law/regulation if known):
____________________________________________________________________________

____________________________________________________________________________

☐ Insufficient Evidence Considered
The decision fails to consider relevant evidence.
Evidence not considered:
____________________________________________________________________________

____________________________________________________________________________

☐ New Evidence Available
New evidence has become available since the original decision.
Description of new evidence:
____________________________________________________________________________

____________________________________________________________________________

☐ Medical Evidence Supports Claim
Medical evidence establishes that the injury/condition is work-related.
Explanation:
____________________________________________________________________________

____________________________________________________________________________

☐ Procedural Error
The decision was made in violation of proper procedures.
Explanation:
____________________________________________________________________________

____________________________________________________________________________

☐ Abuse of Discretion
The decision represents an abuse of discretion.
Explanation:
____________________________________________________________________________

____________________________________________________________________________

☐ Change in Circumstances
Circumstances have changed since the original decision.
Explanation:
____________________________________________________________________________

____________________________________________________________________________

☐ Other
[SPECIFY GROUNDS]
____________________________________________________________________________

____________________________________________________________________________

5.2 Detailed Argument

Statement of Facts:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Argument:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

SECTION 6: RELIEF REQUESTED

6.1 Specific Relief Sought

I/We respectfully request the following relief:

☐ Reversal of Claim Denial
Accept the claim as compensable and provide all benefits to which claimant is entitled.

☐ Award of Temporary Disability Benefits
Award temporary total/partial disability benefits from [DATE] through [DATE/ONGOING].
Calculated weekly rate: $[AMOUNT]

☐ Award of Permanent Disability Benefits
Award permanent disability benefits based on [PERCENTAGE]% permanent disability.

☐ Authorization of Medical Treatment
Authorize the following medical treatment:
____________________________________________________________________________

☐ Reimbursement of Medical Expenses
Reimburse claimant for out-of-pocket medical expenses totaling $[AMOUNT].

☐ Award of Supplemental Job Displacement Benefit
Issue SJDB voucher in the amount of $[AMOUNT].

☐ Award of Death Benefits
Award death benefits to eligible dependents.

☐ Award of Mileage/Travel Expenses
Reimburse claimant for mileage and travel expenses totaling $[AMOUNT].

☐ Penalties
Award penalties for unreasonable delay/denial pursuant to [CITE STATUTE].

☐ Interest
Award interest on unpaid benefits from [DATE].

☐ Attorney Fees
Award reasonable attorney fees.

☐ Costs
Award costs of this appeal.

☐ Reconsideration of Permanent Disability Rating
Reconsider permanent disability rating based on [EXPLAIN].

☐ Other Relief
[SPECIFY]
____________________________________________________________________________

6.2 Estimated Value of Benefits in Dispute

Temporary Disability: $[AMOUNT]

Permanent Disability: $[AMOUNT]

Medical Treatment: $[AMOUNT]

Other Benefits: $[AMOUNT]

Total Value in Dispute: $[TOTAL]

SECTION 7: SUPPORTING EVIDENCE

7.1 Documents Attached

The following documents are attached in support of this appeal:

☐ Copy of denial letter/decision being appealed dated [DATE]
☐ Medical report(s) from [PHYSICIAN NAME] dated [DATE]
☐ Medical records from [PROVIDER] dated [DATE]
☐ Treating physician's declaration/statement dated [DATE]
☐ QME/AME report from [PHYSICIAN NAME] dated [DATE]
☐ Witness statement(s) from [NAME] dated [DATE]
☐ Employment records
☐ Wage documentation
☐ Job description
☐ Photographs
☐ Prior workers' compensation decision(s)
☐ Correspondence with claims administrator
☐ Other: [SPECIFY]

7.2 Evidence to Be Obtained

The following evidence will be submitted prior to hearing:

☐ Additional medical reports
☐ Deposition transcripts
☐ Expert witness declarations
☐ Other: [SPECIFY]

Estimated time needed to obtain additional evidence: [TIME PERIOD]

7.3 Witnesses

Witnesses I/we intend to call at hearing:

SECTION 8: CLAIMANT CERTIFICATION

I, [CLAIMANT NAME], declare under penalty of perjury under the laws of the State of [STATE] that:

☐ The information contained in this appeal is true and correct to the best of my knowledge.

☐ I have read and understand this appeal document.

☐ I understand that this appeal must be filed within the applicable deadline to preserve my rights.

☐ I authorize my attorney/representative (if any) to act on my behalf in this appeal.

☐ I understand that I have the right to be represented by an attorney.

☐ I agree to appear at any scheduled hearings or depositions.

Claimant Signature: _________________________________

Date: [DATE]

Attorney/Representative Certification (if applicable):

I certify that I am authorized to file this appeal on behalf of the claimant and that the foregoing statements are true to the best of my knowledge, information, and belief.

Attorney/Representative Signature: _________________________________

Printed Name: [NAME]

Bar Number: [NUMBER]

Date: [DATE]

SECTION 9: FILING INSTRUCTIONS AND DEADLINES

9.1 Where to File

File this appeal with:

Agency Name: [STATE WORKERS' COMPENSATION BOARD/COMMISSION]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE NUMBER]

Fax: [FAX NUMBER]

Electronic Filing: [WEBSITE/SYSTEM]

Local District Office (if applicable):
[ADDRESS]

9.2 Filing Deadlines

IMPORTANT: FAILURE TO FILE BY THE DEADLINE MAY RESULT IN LOSS OF APPEAL RIGHTS.

Common Deadlines by State:

Your Filing Deadline: [CALCULATE AND INSERT SPECIFIC DATE]

Date of Decision Being Appealed: [DATE]

Days Remaining to File: [NUMBER]

9.3 Filing Fee

☐ No filing fee required
☐ Filing fee required: $[AMOUNT]
☐ Fee waiver requested (financial hardship)

9.4 Number of Copies Required

Original plus [NUMBER] copies

SECTION 10: SERVICE OF PROCESS

10.1 Proof of Service

I declare that on [DATE], I served a true copy of this appeal on the following parties:

Defendant/Insurance Carrier:
Name: [NAME]
Address: [ADDRESS]
Method: ☐ First Class Mail ☐ Certified Mail ☐ Personal Service ☐ Fax ☐ Email ☐ Electronic Filing System

Employer:
Name: [NAME]
Address: [ADDRESS]
Method: ☐ First Class Mail ☐ Certified Mail ☐ Personal Service ☐ Fax ☐ Email

Defense Attorney:
Name: [NAME]
Address: [ADDRESS]
Method: ☐ First Class Mail ☐ Certified Mail ☐ Personal Service ☐ Fax ☐ Email

10.2 Declaration of Service

I declare under penalty of perjury that I am over 18 years of age and not a party to this action. I served the foregoing document as indicated above.

Signature: _________________________________

Printed Name: [NAME]

Date: [DATE]

SECTION 11: REQUEST FOR EXPEDITED HEARING (IF APPLICABLE)

☐ I request expedited/priority hearing for the following reasons:

☐ Claimant is experiencing severe financial hardship
☐ Claimant requires urgent medical treatment
☐ Claimant's condition is worsening
☐ Other exigent circumstances: [EXPLAIN]

Explanation:
____________________________________________________________________________

____________________________________________________________________________

SECTION 12: ADDITIONAL STATE-SPECIFIC REQUIREMENTS

California:

☐ Application for Adjudication of Claim filed: ☐ Yes ☐ No (ADJ#: [NUMBER])
☐ Declaration of Readiness to Proceed attached
☐ Request for Independent Medical Review (if treatment dispute)

Texas:

☐ Request for Benefit Review Conference (DWC-45) filed
☐ Dispute Resolution Information Sheet attached

New York:

☐ Form C-3 (Employee Claim) filed
☐ Request for Hearing (EC-3) attached

[YOUR STATE]:

[INSERT STATE-SPECIFIC REQUIREMENTS]

[END OF DOCUMENT]