Regulations of the Settlement Labor Insurance Disputes Article 4
The Application Form for the Settlement shall be recorded clearly the following items with signature or seal by the applicants or representatives:1. The Insured Persons' and the applicants' name, birthrates (Year, Month, Day), resident address, serial number of identification document. If it was applied by the Insured Unit, shall be recorded clearly name, serial number of Insurance Certificate, address and name of the person in charge.2. The original appraised and decided date (Year, Month, Day) of the received or informed by BLI.3. The request particulars of the application for examination or review.4. The facts and reasons of the application for examination or review.5. Evidences, for those are papers, shall add copy or photocopy.6. Year, Month, Day.Application for examination or review shall attach the photocopy of original appraised decided letter from BLI.
中文原文 勞工保險爭議事項審議辦法第4條
審議申請書應載明下列事項，由申請人或代理人簽名或蓋章：
一、被保險人及申請人之姓名、出生年月日、住、居所、身分證明文件字號。
如係投保單位申請，應記明名稱、保險證字號、地址及負責人姓名。
二、收受或知悉勞保局原核定之年月日。
三、申請審議之請求事項。
四、申請審議之事實及理由。
五、證據，其為文書者，應添具繕本或影本。
六、年、月、日。
申請審議應附勞保局原核定函影本。
一、被保險人及申請人之姓名、出生年月日、住、居所、身分證明文件字號。
如係投保單位申請，應記明名稱、保險證字號、地址及負責人姓名。
二、收受或知悉勞保局原核定之年月日。
三、申請審議之請求事項。
四、申請審議之事實及理由。
五、證據，其為文書者，應添具繕本或影本。
六、年、月、日。
申請審議應附勞保局原核定函影本。