TDI/FLI Employer Appeal Request

Thank you for contacting the Division of Temporary Disability and Family Leave Insurance. If you don’t agree with the determination you received, please fill out the following fields with as much detail as possible.

Employee Information

First name

Middle name

Last name

Suffix

Mailing address

Address line 2

City

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ZIP code

Social Security Number

Employer Information

Company name

Contact name

Postion

Phone number

Email address

Is this a Temporary Disability or Family Leave claim? Value is not selected

Date of claim

Date of determination being appealed

Reason for appeal

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TDI/FLI Employer Appeal Request

Employee Information

Employer Information