INS5210 Form PDF Details

The Ins 5210 form serves as a crucial document for individuals seeking to challenge an Employment Insurance (EI) decision in Canada, marking the first step towards reassessment by Service Canada. Designed to accommodate requests from various parties including claimants, employers, and other interested entities, this form emphasizes the provision of detailed information to support the request for reconsideration. Applicants must provide their personal details, the specific EI decision in question, the reasons behind their disagreement with the decision, and any additional information not previously shared with Service Canada. The form also outlines clear guidelines for submission deadlines, specifically indicating that requests must be filed within 30 days following the initial decision notification unless justified reasons for delay are provided. Furthermore, it stresses the importance of consent and authorization for requests made on behalf of another party, in compliance with privacy legislation. The completion and submission of this form, along with all relevant documentation, are fundamental steps for those who seek to have their EI decisions revisited, making accuracy and timeliness crucial elements in the process.

QuestionAnswer
Form NameINS5210 Form
Form Length2 pages
Fillable?Yes
Fillable fields1
Avg. time to fill out42 sec
Other namesservice canada ins 5210, sc ins5210, request for reconsideration canada forms ins5210, service canada form ins5210

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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.

Signature

Telephone number (where you can be contacted in the next 2 weeks):

Date

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)

1. Are you submitting this request for reconsideration on behalf of a claimant or an employer?

Yes

No

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.

2. Are you a person, other than a claimant or an employer, who is the subject of a decision of the Commission?

Yes

No

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.

Signature

Date

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

 

 

SC INS5210 (2013 06 005) E

Page 2 of 2

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