Total disability



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State of New Jersey

Department of Labor and Workforce Development

DIVISION OF WORKERS’ COMPENSATION
WC-374i (3/19/13)


ORDER FOR

TOTAL DISABILITY


CASE NO’S.:      


VICINAGE:




PETITIONER

SOCIAL SECURITY NUMBER:

     


ATTORNEY FOR PETITIONER

SSN FEDERAL EMPLOYER NUMBER NJ REG NUMBER

     


NAME:

     


NAME::

     


DATE OF BIRTH:

     


MEDICARE ELIGIBLE:

YES NO

ADDRESS:

     




ADDRESS (Including County):

     


TELEPHONE NUMBER (AREA CODE):

     


RESPONDENT

vs

APPEARING:

     


NAME:

     





ADDRESS (Including County):

     




INSURANCE

CARRIER

NAME : SELF-INSURED TPA

     


CLAIM NUMBER;

     


ATTORNEY FOR RESPONDENT

NAME:

     


DATE OF ACCIDENT OR

OCCUPATIONAL EXPOSURE:      



ADDRESS:

     


DESCRIBE (Briefly):

     


TELEPHONE NUMBER (AREA CODE):

     



APPEARING:

     








Weekly Wages: $      

Rate(s): $       / $      




IF RE-OPENED PETITION, INDICATE FOR LAST AWARD: DATE:      

PERMANENT: $       TEMP: $      
This matter having come before the COURT on this       day of , :






ORDER FOR JUDGMENT

It appearing that the Petitioner suffered a compensable injury on the above mentioned date while in the

employ of respondent;

It is Ordered and Adjudged that Petitioner be awarded compensation benefits, payable as set forth below.






ORDER APPROVING SETTLEMENT

The parties having settled the matter and a finding by the Court having been made that the terms of the

settlement are fair and just;

It is Ordered that this settlement be approved and the petitioner be paid as set forth below.






PERMANENT DISABILITY:
     




State of New Jersey

Department of Labor and Workforce Development



DIVISION OF WORKERS’ COMPENSATION
WC-374i (8-14-09)

ORDER FOR

TOTAL DISABILITY

Page 2


CASE NO’S.: Error: Reference source not found


VICINAGE: Error: Reference source not found




TEMPORARY:

     

Weeks at $

     

= $

     

less $

     

paid = Balance due $

     































PERMANENT:

     

Weeks at $

     

= $

     

less $

     

paid = Balance due $

     






















Voluntary Tender Reopener Credit




MEDICAL BILLS (Doctors and/or Institutions):

     




An application for Social Security Disability Benefits and / or Government Ordinary Disability Pension

is pending is on appeal has not been filed. Should Petitioner be awarded Social Security Disability Benefits and / or Government Ordinary Disability Pension, Petitioner shall immediately notify the Respondent of this award. The Petitioner shall reimburse the Respondent for any workers’ compensation benefits paid to Petitioner in excess of the statutory offset rate during the period of time Petitioner has received Social Security Disability benefits or Government Ordinary Disability Pension.
In the event there is a change in the number or status of the auxiliary beneficiaries while Petitioner is receiving Workers’ Compensation benefits, Petitioner shall immediately notify the Respondent.
I further Order that Respondent furnish the Petitioner such medical attention, prosthesis, and medical supplies as the condition of the Petitioner may require. Should any emergency arise, necessitating immediate medical attention for the Petitioner, notice and request to Respondent shall not be necessary.
Respondent authorizes       as treating physician.
The date of Petitioner’s Permanent Total disability is       .
On       which is the expiration of the 450 week period, benefits to continue in accordance with the provision of N.J.S.A. 34:15-12(b) as amended.
Pursuant to N.J.S.A. 34:15-12(b), petitioner will be referred to the Division of Vocational Rehabilitation Services for evaluation and services prior to the expiration of 450 weeks from the date of Total Permanent Disability.






State of New Jersey

Department of Labor and Workforce Development

DIVISION OF WORKERS’ COMPENSATION
WC-374i (8-14-09)


ORDER FOR

TOTAL DISABILITY

Page 3


CASE NO’S.: Error: Reference source not found


VICINAGE: Error: Reference source not found






REIMBURSE

TAX IDENTIFICATION NUMBER

TOTAL AMT. ALLOWED

PAYABLE BY PETITIONER

PAYABLE BY RESPONDENT

MEDICAL FEE ALLOWED: (expert and/or testimonial)      



     


     

     

     

     

     



     


     

     

     

     

     



     


     

     

     

     

     



     


     

     

     

     

     

     


     

     

     

     

ATTORNEY(S) FEE:

     




     



Error: Reference source not found

     

     

     

STENOGRAPHIC SERVICE:

     


     

     

     

     

MISCELLANEOUS FEES: (fill in below)

     



     


     

     

     

     

     


     


     

     

     

     

     


     


     

     

     

     

     


     


     

     

     

     


ORDER FOR CHILD SUPPORT ADDENDUM ATTACHED


MEDICARE ELIGIBILITY: PETITIONER ( IS) ( IS NOT) ELIGIBLE FOR MEDICARE



     

JUDGE OF COMPENSATION



DATE




WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY:














Error: Reference source not found, Error: Reference source not found

Petitioner’s Attorney






Error: Reference source not found, Error: Reference source not found

Respondent’s Attorney










Petitioner (where applicable)








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