Appeal of a Hearing Officer's Decision
If either you or your representative participated in the previous hearing and you disagree with the Hearing Officer’s Decision, you may use this form to appeal the decision.

If neither you nor an authorized representative participated at the hearing that was held, you may request a new hearing. Please complete and submit the Request for New Hearing Form to request a new hearing:

PLEASE NOTE: A copy of the completed form will be provided to the opposing party.

If you require assistance with this form, please contact the Industrial Claim Appeals Office at

Email address *
Appealing Party *
Please select which party is appealing the decision.
Hearing Officer's Decision Date *
Please enter the date the Hearing Officer's Decision was mailed.
Your answer
Docket Number *
The docket number is found below the Social Security Number on the Hearing Decision.
Your answer
Claimant Name *
Please enter the name of the Claimant from the Hearing Decision.
Your answer
Social Security Number (Claimant) *
Please enter the last 4 digits of the Claimant's Social Security Number.
Your answer
Employer Name *
Please enter the name of the Employer from the Hearing Decision.
Your answer
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This form was created inside of Executive Branch.