Wisconsin Labor and Industry Review Commission

Form For Electronic Filing of Petition for Commission Review (Unemployment Insurance)

To file a petition for review electronically, complete this form and follow the filing instructions below. Fields marked with an asterisk (*) are mandatory and must be completed.

PLEASE NOTE: This form may NOT be used to appeal an Initial Determination. It may ONLY be used to appeal an Administrative Law Judge's Appeal Tribunal Decision.

I hereby petition for review by the Labor and Industry Review Commission of the ALJ's decision in the following Unemployment Insurance matter:

(Instructions are shown to the right of each form field)

Petition Information:

* Required Field Hearing Number(s):

Enter the hearing number(s) shown on the first page of the Appeal Tribunal Decision.

* Required Field Date of Decision:

Enter the date shown in the "Dated and Mailed" box on the first page of the Appeal Tribunal Decision.

Statement Regarding Timeliness of Petition:

If this petition is not being filed by the date in the "Appeal Deadline" box on the Appeal Tribunal Decision, provide a specific and complete explanation why here.

Employee:

Enter the name of the employee shown on the first page of the Appeal Tribunal Decision (if no employee name is shown on the ATD, this box may be left blank).

Employer:

Enter the name of the employer shown on the first page of the Appeal Tribunal Decision (if no employer name is shown on the ATD, this box may be left blank).

Statement of Reasons for Petition:

A statement of the reasons this petition is being filed may be entered here. (Optional)

Information about the person filing this petition:

* Required Field Your Name:

The person filing this petition should enter his or her name here, and indicate if he or she is the employee or the employer, an attorney or representative of the employee or the employer, or if this is a petition by the department.

I am the:

Employee
Employee's Atty/Representative

Employer
Employer's Atty/Representative

Department

* Required Field Address:

The person filing this petition should enter his or her mailing address here.

* Required Field City:

The person filing this petition should enter his or her city here.

* Required Field State:

The person filing this petition should enter his or her state here.

* Required Field 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)

Filing instructions:

PLEASE NOTE: This form may NOT be used to appeal an Initial Determination. It may ONLY be used to appeal an Administrative Law Judge's Appeal Tribunal Decision.
Before you proceed, check the information entered above to ensure that it is complete and correct.
After you click the "File Petition" button below, you should see a confirmation page. Your petition is not filed until you see this confirmation page. If you do NOT see the confirmation page, or you are for any other reason unable to complete the electronic filing process, you must use another means to file your petition.

You should print and keep a copy of the confirmation page. If there is a question about whether or when you filed a petition, you may be asked to produce a copy of that page.
If you have questions about how to complete or use this form, you may contact the commission by telephone during normal business hours (7:45 AM to 4:30 PM), at 608-266-9850.
To file your petition, click on the "FILE PETITION" button below -

LIR-15356-E (R.10/2010)