TDI/FLI Employer Appeal Request

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

Social Security Number

Employer Information

Company name

Contact name

Position

Phone number

Email address

Date of claim

Date of determination being appealed

Reason for appeal

Please upload any relevant documentation.

Your session has timed out.

Click here to access the application.

TDI/FLI Employer Appeal Request

Employee Information

Employer Information