Request a Reconsideration

Reconsideration Form

What type of reconsideration are you requesting?

I am requesting a reconsideration of a decision made on one of my employee’s claimsI am requesting a reconsideration of my nationwide employee headcountI am requesting a reconsideration of premiums, fees, or penalties charged to my account

Full name of Requestor

Phone Number

Email Address

Claim Number

Leave Type

Account Name

FEIN

Nationwide Employee Headcount Year

Nationwide Employee Headcount

1-9 10+

Reason for Reconsideration (Describe)

Reconsideration details: Amount and Date

To request a reasonable accommodation, or this form in an alternate accessible format, please refer to our department's Accessibility website and complete the Accessibility Feedback Form .

Security Question

What is 5+5?

This text box helps to prevent spam and ensures that only humans are submitting this form.

Thank you!

Thank you for submitting the form. We will contact you soon!