Manage Your Performance and Costs
WCB Information > Request a review form

Request for review

Fill out the form below to request a review and click Submit. Either a claim number or account number is required.

Note: * indicates a required field

* Claim Number:
(for requests from workers or employers about a claim decision)
* Account Number:
(for requests from employers about a WCB account decision)
* Name:
Role/Position:
* Address:
* City/Town:
* Postal Code:
* Phone # (with area code):
Email (optional):
  I disagree with the decision of Customer Service concerning this claim/account and request the decision be reviewed.
* What is the decision you wish to have reviewed? (be as specific as possible)
* What is the date of the letter sent to you that explains the decision?
mm/dd/yyyy
* What are your reasons for requesting a review of this decision? (be as specific as possible)
* What results do you want from this review? (be as specific as possible)
* Do you have a representative to act on your behalf?

If yes, Representative name: