Get Employees'' Compensation Appeals Board Application ... - Dol

The Employees' Compensation Appeals Board Application is a crucial document for individuals seeking to appeal decisions made by the Office of Workers' Compensation Programs. This guide provides clear, step-by-step instructions to help you complete this application accurately and efficiently, ensuring that your appeal is properly submitted.

Follow the steps to complete your application effectively.

1. Press the ‘Get Form’ button to obtain the application form and open it in your chosen editor.
2. In the first section, provide your personal information by entering your first, middle, and last name. If applicable, include the name of the deceased employee in section 1a.
3. Input the date of the OWCP decision you are appealing in section 2. Remember, your appeal may be dismissed if this date is not provided.
4. Fill in your street address, along with your city, state, and zip code in section 3.
5. Enter your telephone number(s) in section 4 for any follow-up communication.
6. Provide the OWCP case file or claim number in section 5.
7. In section 6, briefly state the specific reasons for your disagreement with the OWCP decision. You can use additional sheets if necessary.
8. Indicate whether you are requesting oral argument in section 7 by selecting ‘Yes’ or ‘No’. If requesting, detail specific issues and reasons for this request.
9. Sign and date the application in section 8. This confirms your acknowledgment of the information provided.
10. If you have an authorized representative, include their name and address in section 9, and ensure they sign in section 10 consenting to represent you.
11. Once you have completed all sections, you can save changes, download, print, or share the form as needed.

Take action now and complete your Employees' Compensation Appeals Board Application online to move forward with your appeal.