INS5210 Form – Fill Out and Use This PDF

	Service
	Canada	PROTECTED WHEN COMPLETED – B
	REQUEST FOR RECONSIDERATION	Social Insurance Number
of an Employment Insurance (EI) decision
		Name of Claimant or Other Person
Are you:	a claimant
	an employer
		Canada Revenue Agency Business Number
	an other interested party or person (see section 6)
	FOR OFFICE USE ONLY	Name of Employer
Date of Receipt of this Request for Reconsideration

Personal information on this form is collected under the authority of the Employment Insurance Act. This information will be used to assess your request for a reconsideration of an Employment Insurance decision. The information you provide on this form will be retained in a Personal Information Bank titled the "E.I. Claim File” (ESDC/PPU-150). Your personal information is protected and accessible under the Privacy Act and the Access to Information Act. Instructions for accessing your personal information are given in the Info Source publication at infosource.gc.ca or at your Service Canada Centre.

SECTION 1: REQUESTOR INFORMATION

Name of Requestor:

Mailing Address:

City:		Province:		Postal Code:
Telephone number	Cell number:		Telephone number		E-mail
(home):			(daytime):		address:

SECTION 2: DECISION(S) TO BE RECONSIDERED

1. Which Employment Insurance decision or decisions would you like to have reconsidered ?

2.Date the decision was verbally communicated to you, if applicable:

3.Date the decision letter was sent to you (indicate all dates if more than one decision letter is applicable):

If you are not sure of the decision or decisions made in your case, please contact Service Canada at 1-800-206-7218.

SECTION 3 : REASON FOR REQUEST FOR RECONSIDERATION

Explain why you disagree with the decision or decisions. It is important you include any additional information which you may not have provided to Service Canada at the time the original decision was made (attach additional pages if required).

SECTION 4: NOTICE OF REQUEST FOR RECONSIDERATION

IMPORTANT: The request to have an Employment Insurance decision reconsidered must be submitted to Service Canada within 30 days of when you received the notice of decision.

I hereby give notice that I disagree with an Employment Insurance decision regarding my claim for benefits (or regarding a former employee’s claim for benefits if you are an employer) and wish to exercise my right to request a reconsideration of this decision. I declare that the information on this form is true and accurate and that I have disclosed all information and attached all relevant documents.

SC INS5210 (2013 06 005) E

Page 1 of 2

Social Insurance Number

SECTION 5: LATE REQUEST FOR RECONSIDERATION (To be completed only if more than 30 days have passed since the decision was communicated to you)

IMPORTANT: If this Request for Reconsideration is being filed more than 30 days after the Commission's decision was communicated to you, you must explain why you require the time period to be extended.

1. Date the decision for which you are requesting a reconsideration was communicated to you:

(year, month, day)

2.Please explain the reasons for the delay in filing your request for reconsideration: (Attach additional pages if required).

SECTION 6: OTHER PERSON OR INTERESTED PARTY (To be completed only if you are not a claimant or an employer)

If yes, please specify who you are representing.

NOTE: We cannot release any information to you until we obtain a written consent from the person you are representing. Privacy legislation ensures that no information regarding a client can be released to another person unless the client has given permission in writing. Authorization means written documentation, either a letter or a consent form (ESDC ADM3124). The consent must be voluntary, the specific purpose for which consent is being given must be stated, the information to be released must be identified, and it must be signed and dated by the client.

If yes, please provide details or explanation on why you are subject to the decision.

IMPORTANT: We may have to contact you in the next two weeks. Please ensure the telephone numbers in Sections 1 and 4 are accurate.

MAILING INSTRUCTIONS

Mail the completed form, including all pertinent documentation, to your regional Service Canada Processing Centre:

Atlantic: Service Canada	Quebec: Service Canada	Ontario: Service Canada	Western and Service Canada
P.O. Box 8548	Boucherville Processing Centre	P.O. Box 5711	Territories: P.O. Box 245
St. John’s, Newfoundland	P.O. Box 60	London, Ontario	Edmonton, Alberta
A1B 3P3	Boucherville, Quebec	N6A 4S7	T5J 2J1
	J4B 5E6