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State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC(DO)-100 PDF (r. 3/18/09)
NAME:

ORDER
JUDGMENT APPROVING SETTLEMENT

CASE NO'S.:

VICINAGE:

FEDERAL EMPLOYER NUMBER

DATE OF BIRTH:

ATTORNEY FOR PETITIONER

PETITIONER

NAME:

ADDRESS:

ADDRESS:

vs
RESPONDENT
NAME:

TELEPHONE NUMBER (AREA CODE): APPEARING:

ADDRESS:

NAME

SELF-INSURED

TPA

INSURANCE CARRIER

ADDRESS:

NAME: ADDRESS:

ATTORNEY FOR RESPONDENT

CLAIM NUMBER:

DATE OF ACCIDENT OR OCCUPATIONAL EXPOSURE: TELEPHONE NUMBER (AREA CODE): DESCRIBE (Briefly):

APPEARING:

Weekly Wages :

$

Rate(s):

$

/

$

IF RE-OPENED PETITION, INDICATE FOR LAST AWARD: Date: Permanent Paid: $ Temporary Paid: DAY OF $ ,

THIS MATTER HAVING COME BEFORE THE COURT ON THIS

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 indicated on Page 2.

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 indicated on page 2. PERMANENT DISABILITY (Describe Percentages below followed by the Nature and Extent of Injury and Members involved):

% of

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC(DO)-100 Interactive (r. 3/18/09)

ORDER
JUDGMENT APPROVING SETTLEMENT

CASE NO'S.:

VICINAGE:

DISABILITY AWARDED: TEMPORARY: PERMANENT:

weeks at $ weeks at $

=$ =$

less $ less $
Voluntary Tender

paid = Balance due $ paid = Balance due $
Reopener Credit N.J.S.A. 34:15-40

MEDICAL BILLS (Doctors and/or Institutions) AND/OR MISCELLANEOUS INFORMATION:

ORDER FOR CHILD SUPPORT ALLOWANCES
MEDICAL FEE ALLOWED: (report and/or testimony)

ADDENDUM ATTACHED
REIMBURSE TAX IDENTIFICATION NUMBER TOTAL AMT. ALLOWED PAYABLE BY PETITIONER PAYABLE BY RESPONDENT

INTERPRETER:

ATTORNEY(S) FEE: STENOGRAPHIC SERVICE

MISCELLANEOUS FEES: (list below)

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

PETITIONER'S ATTORNEY

JUDGE OF COMPENSATION

DATE

PETITIONER (where applicable)

JUDGE'S NAME THE ORIGINAL OF THIS DOCUMENT, SIGNED BY THE JUDGE OF COMPENSATION, WILL BE MAINTAINED ON FILE IN THE DIVISION OF WORKERS' COMPENSATION, PURSUANT TO N.J.S.A. 34:15-121 et. seq.

RESPONDENT'S ATTORNEY

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION
WC-168 r. 3/18/09

CASE NO'S.:

CASE EXHIBIT LISTING
FOR: PETITIONER RESPONDENT VICINAGE:

Judge: Petitioner: Petitioner Attorney: Respondent: Respondent Attorney:
Retained Court Atty.

Hearing Date

No.

ID

Ev.

Description

Reporter

Page

of