DECISION RECONSIDERATION REQUEST SETTLEMENT DOCCase Manager`s Manager

DECISION RECONSIDERATION REQUEST SETTLEMENT DOC

Step 2 - Case Manager's Manager
Date*

MonthDayYear
Date
Your Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / 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

PrefixFirst NameLast 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

Clear
Your Name

First NameLast Name
WSIB Settlements

First NameLast Name
Should be Empty: