Document Submittal Form - Voluntary Dismissal of Appeal

To be used only by the appealing party or their representative.


  • You must have a docket number.
  • Use a separate transmission for each appeal being dismissed. Transmissions containing more than one docket number will be rejected and filing will not be accomplished. Submit in electronic format only. After successful submission, DO NOT SEND A HARD COPY.
  • You must enter an email address to receive email confirmation of successful submission.
  • If you do not see "Your document has been submitted." your form has NOT been received by the BIIA.
  • Documents received after 5 p.m. will be deemed filed the next business day. WAC 263-12-015(3) and WAC 263-12-01501.

QUESTIONS: Please call 360-753-6823.

Submitter information

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Your name:*  
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Document information

BIIA Docket number:*                                                                                                         
By submitting this request, I certify that I filed this appeal; or that my provider did so on my behalf; or that I represent the individual who filed this appeal. I understand this action will end the appeal, the L&I decision will not be changed, and no further appeal can be filed from this L&I decision.