DECISION RECONSIDERATION REQUEST SETTLEMENT DOC

DECISION RECONSIDERATION REQUEST SETTLEMENT DOC

Step 1 - Case 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 the reconsideration decision of your Case Manager's Manager*
MM/DD//YYYY
Case 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 are as follows:

1.
0/300
Signature

Clear
Your Name

First NameLast Name
WSIB Settlements

First NameLast Name
Should be Empty: