|
< Date >
< Your Adjudicator's Name
>
< Your Adjudicator's Address >
Dear Mr(s). < Adjudicator's Name >,
| Re: |
Request
to Appeal My NEL Assessment
< Your Name > |
| WSIB Claim No.: |
<
Your Claim Number > |
I am writing to object to the amount of my
NEL award.
In your letter of < Date >,
you stated that I will be receiving an award of $3,000 < enter
Amount of Award > based on the examination by Dr. Loss
< enter name of WSIB selected Doctor >.
Please find enclosed a letter from Dr. Bones < enter Doctor's
Name>, my orthopaedic specialist < enter Doctor's
area of expertise >. According to her, the measurements
for the range of motion in my back given in the assessment report
are incorrect. Please see her report for the correct measurements.
In light of the serious problems with Dr. Loss's
examination, please refer me for a new examination so that my NEL
award can be properly calculated. If you cannot change your original
decision regarding the amount of my NEL award, please refer this
matter to the next level of appeal without further delay.
Thank you for your attention to this matter.
Yours truly,
< Sign Your Name Here >
< Type/Print Your Name >
< 123 Your Street >
< Your City, Ontario >
< X0X 0X0 >
Enclosure
|
