| BETWEEN: |
| Appellant |
| And |
| Respondent |
| Take notice that (1) |
| , an insurer, insurance agent, insurance broker, insurance |
| salesman or a representative or a person affected by the decision of the Authority, |
| (2) hereby apply to the Insurance |
| Appeals Tribunal to extend the time within which I may appeal against the decision of the Authority dated the |
| day of 20 of which I received notice on |
| the day of 20 |
| That (3) |
| |
| |
| |
| |
| And further take notice that the reasons for this application are as follows — (4) |
| (a) |
| (b) |
| (c) |
| (d) etc. |
| And further take notice that the time required is |
| (5) |
| |
| All notices or other documents relating to this application may be sent to me at (6) |
| |
| Dated this day of 20 |
| Appellant |
| To: The Secretary |
| The Insurance Appeals Tribunal |
| Note: |
| (1) Name of Appellant |
| (2) Occupation/office |
| (3) Insert substance of the decision appealed against |
| (4) Insert reasons for being out of time |
| (5) Insert number of days and date by which appeal will be made |
| (6) Address. |