This form is intended to be printed, completed and mailed through the U.S. Postal Service. Forms or replications of forms returned by e-mail will not be accepted for processing.

Board of Industrial Insurance Appeals
PO Box 42401, Olympia, WA 98504-2401

WISHA NOTICE OF APPEAL

If you disagree with a decision of the Department of Labor & Industries concerning a WISHA citation and notice (CN) or Corrective Notice of Redetermination (CNR), this form can be used to file an appeal of that decision. You must file the appeal with the Board of Industrial Insurance Appeals, WITHIN 15 WORKING DAYS of the date you received the Department's decision. The appeal can be filed with the Board personally or by mail at the above address.

Today's date: __________________

*required field

 

Citation and Notice No./Citation and Notice of Reconsideration No*______________________________________.

I wish to appeal the CN/CNR of the Department of L & I dated:*____________________

Employer:*_______________________________________

Business Mailing Address*:__________________________________________________________________

City*: _______________________________State*:  _____________  Zip*:_________

I disagree with the Department's determination because: ____________________________________________


_______________________________________________________________________________________________________

I believe the Board should give the employer the following relief: (vacate/modify)_________________________

I desire to have any proceedings held in: (City)______________________________

Do your employees belong to a Union*?   ___Yes  ____No

If so, please provide the name of union(s), business agent's name, address and phone number*:

INTERESTED EMPLOYEES OF THIS APPEAL HAVE BEEN NOTIFIED by*:

___Posting a copy of the notice of appeal at the work site.  ________Date

___Providing copies of the notice of appeal to employee member so the safety committee.  __________ Date

FAILURE TO COMPLETE THE ABOVE REQUIRED INFORMATION MAY REQUIRE THE BOARD TO SET ASIDE THE FINAL DECISION IT WILL ENTER IN YOUR APPEAL.

I certify under penalty of perjury under the laws of the State of Washington, that the above information is true and correct to the best of my knowledge.*

Dated this  _____day of __________________, 20____ at ______________________, WA


Signature____________________________________________________________________

Phone:  *(H)                                                                (W)
 

Please print name*:
 

Address*:

City*:                                                 State*:                                               Zip*:

It is important that the Board be able to reach you concerning your appeal. If you do not have a phone, please provide a number where a message can be left. Also, please notify the Board if you have a change of address.