Workers' Comp Appeal letter template

Template preview

[DATE]

[RECIPIENT NAME]
[RECIPIENT ADDRESS]

Re: Appeal of Workers' Compensation Claim #[CLAIM NUMBER] — Injury Date [INJURY DATE]

To the Claims Review Board:

I am appealing the denial/reduction of my workers' compensation claim for an injury sustained on [INJURY DATE] in the course of my employment. The stated reason — "[DENIAL REASON]" — is not consistent with the medical record or the circumstances of the injury.

Facts:
[FACTS]

Requested resolution:
[DESIRED OUTCOME]

I request that this appeal be docketed with the state workers' compensation appeal board, that all medical and wage-loss benefits be reinstated retroactively, and that you provide the complete claim file, including the basis for denial, within the time required by state law.

Sincerely,

[USER FULL NAME]
[USER ADDRESS]

Bracketed fields are filled in automatically from your answers, then rewritten by AI into a professional letter in your own voice.

What you'll need

• • Recipient
• • Recipient address
• • Your name
• • Your address
• • Injury date
• • Claim number
• • Denial reason
• • Facts
• • Desired outcome