INS5210 Form PDF Details

Are you confused about how to complete the INS5210 Form? You're not alone - understanding insurance paperwork can be a challenge. Knowing if and when you need this form and what information is required can quickly become overwhelming. In this blog post, we'll provide a comprehensive overview of the INS5210 Form so that you understand exactly what it's all about, why it's necessary, and how to properly complete it. Read on for more information!

Form NameINS5210 Form
Form Length2 pages
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

Form Preview Example














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)







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 or at your Service Canada Centre.


Name of Requestor:

Mailing Address:




Postal Code:







Telephone number

Cell number:


Telephone number


















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.


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).


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.


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


SC INS5210 (2013 06 005) E

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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?



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?



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.




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

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ins5210 writing process outlined (part 1)

2. When the previous segment is done, you should insert the required particulars in SECTION DECISIONS TO BE, Year Month Day, Year Month Day, If you are not sure of the, SECTION REASON FOR REQUEST FOR, SECTION NOTICE OF REQUEST FOR, IMPORTANT The request to have an, and I hereby give notice that I allowing you to move forward to the 3rd stage.

IMPORTANT The request to have an, If you are not sure of the, and I hereby give notice that I in ins5210

3. This step is usually easy - fill in every one of the empty fields in Signature, Telephone number where you can be, SC INS E, and Page of to complete the current step.

A way to fill in ins5210 stage 3

4. This fourth section comes with the next few blank fields to fill out: IMPORTANT If this Request for, Date the decision for which you, Year Month Day, Please explain the reasons for, SECTION OTHER PERSON OR, Are you submitting this request, Yes, If yes please specify who you are, and NOTE We cannot release any.

Completing segment 4 of ins5210

People frequently make errors while completing Date the decision for which you in this section. You should double-check everything you type in here.

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ins5210 conclusion process explained (part 5)

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