Submit Request · PRB Washington State

Note: If you're using Internet Explorer, you may not be able to view the webform below. Please view this page in an alternative browser, like Microsoft Edge, Google Chrome, or Firefox.

File your request for Director Review electronically.
For allocation review requests, you will be asked to attach the determination letter you received from your employer. The letter must be in pdf format. Do not attach any other documents at this time. You will have an opportunity to submit documents later.
You will receive confirmation via email when you submit this form.

Employee Information

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Work Phone

Email (your confirmation will be sent here)

Preferred pronoun

Employer

Are you using a representative (union or other)?

NoYes

Generate a new image Play the audio code

Enter the code from the image