Employer Appeal of Claims Decision

Should you have any questions when completing this form, please call the Assistant Scheduling Co-ordinator at (204) 925-6116 or toll free at 1 (855) 925-6110.

Fields marked with (*) are required.

Section A: Employer Information

Section B: Worker Information

Section C: Representative Information

If you will be represented on your appeal, you must provide a separate signed and dated authorization naming your representative.

Section D: Language Interpretation

Any required interpretation services will be arranged by the Appeal Commission.

Section E: Appeal Information

Maximum length: 800 characters

Maximum length: 800 characters

Section F: Appeal Method

Please indicate by which method you wish to pursue your appeal (select one)

Maximum length: 800 characters

The Chief Appeal Commissioner has the final authority to determine the method of appeal.

Once the request has been sent, you will also receive a copy of your application via email. Please save or print the PDF for your records.