Right To Appeal Request

In some States you have a statutory right to appeal a denied consumer request. This form only provides the Appeal Request for States that provide the Right to Appeal. Please complete all the fields to submit the form. To submit a request by phone, you may also call: (888) 972-1010 (Toll-free).

Consumer Information

Employee Information

Job Applicant Information

Business Contact Information

Contractor Information

Authorized Agent Information

Employee Representative Information

Representative Information

Representative Information

Business Representative Information

Contractor Representative Information

Allowed File Types (PDF,JPEG,PNG)

Consumer Right being appealed

Confirmation Number

Please provide the confirmation number provided in the email response.

Reason For Appeal

Please indicate the reason for the Appeal.
You will receive a verification email after you submit this form. It is necessary for you to respond to the email within 45 days to continue processing your request. Requests not verified within 45 days will not be processed and will be closed for lack of verification. Please check your spam folder if you do not see an email from us in your inbox