Petition Information
Claim Number(s):* Enter the claim number(s) as shown on the first page of the ALJ's Decision.
Date of Decision:* Enter the date of the Administrative Law Judge's decision.
Statement Regarding Timeliness of Petition: If this petition is not being filed within 21 days of the date of the Administrative Law Judge's decision, provide a specific and complete explanation why here.Form will not accept a submit if it exceeds 700 characters.
Applicant: Enter the name of the applicant as shown on the first page of the ALJ's Decision.
Employer: Enter the name of the employer as shown on the first page of the ALJ's Decision.
Insurer: Enter the name of the insurer as shown on the first page of the ALJ's Decision.
Statement of Reasons for Petition: Please enter a statement of the reasons this petition is being filed.Form will not accept a submit if it exceeds 700 characters.
*Do you want a Briefing Schedule?
Yes, I want a briefing schedule No, I don't want a briefing schedule
*Do you request a copy of the synopsis?
Yes, I want a copy of the synopsis No, I do not want a copy of the synopsis
*Will you be ordering a transcript?
Yes, I will be ordering a transcript No, I will not be ordering a transcript
Information about the person filing this petition:
Your Name:* The person filing this petition should enter his or her name here, and indicate their role.
I am the:
Employee Employee's Atty/Representative Employer Employer's Atty/Representative Department
Address:* The person filing this petition should enter his or her mailing address here.
City:* The person filing this petition should enter his or her city here.
State:* The person filing this petition should enter his or her state here.
Zip Code:* The person filing this petition should enter his or her zip code here.
Telephone: (Optional)
Email: A confirmation message will be sent to any e-mail address entered here. (Optional)
Please indicate the email of any party or parties who should receive a courtesy copy of this petition (e.g., opposing counsel). An email of the petition will automatically be sent to the email(s) listed below when the petition is filed. You are responsible for entering the email address correctly. The commission is not responsible for errors or omission in the email address provided. A confirmation of the petition will be sent to parties when the petition is processed.
1st CC: A courtesy message will be sent to any e-mail address entered here. (Optional)
2nd CC: A courtesy message will be sent to any e-mail address entered here. (Optional)
3rd CC: A courtesy message will be sent to any e-mail address entered here. (Optional)
