DECISION RECONSIDERATION REQUEST SETTLEMENT DOC
Step 2 - Case Manager's Manager
Date
*
/
Month
/
Day
Year
Date
Your Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Claim Number
*
Date of your Case Manager's decision being reconsidered
MM/DD//YYYY
Manager's Name
Mr.
Mrs.
Prefix
First Name
Last Name
Provide reasons for requesting a reconsideration, in numbered paragraphs, and be as specific as possible
*
My reasons for requesting a reconsideration of the previously noted decision are as follows: 1.
0/500
Signature
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Your Name
First Name
Last Name
WSIB Settlements
First Name
Last Name
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