Total disability

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ORDER FOR TOTAL DISABILITY CASE NO’S.:
PETITIONER SOCIAL SECURITY NUMBER: ATTORNEY FOR PETITIONER
RESPONDENT vs
INSURANCE CARRIER
Weekly Wages: $ Rate(s): $ / $
DATE
ORDER APPROVING SETTLEMENT
PERMANENT DISABILITY:
ORDER FOR TOTAL DISABILITY Page 2 CASE NO’S.: Error: Reference source not found
MEDICAL BILLS (Doctors and/or Institutions):
ORDER FOR TOTAL DISABILITY Page 3 CASE NO’S.: Error: Reference source not found
REIMBURSE TAX IDENTIFICATION NUMBER TOTAL AMT. ALLOWED
ORDER FOR CHILD SUPPORT ADDENDUM ATTACHED
WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY

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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