Free State of New Jersey - New Jersey


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Date: June 25, 2008
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State: New Jersey
Category: Workers Compensation
Author: lawkosn
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Page Size: Letter (8 1/2" x 11")
URL

http://lwd.dol.state.nj.us/labor/forms_pdfs/wc/pdf/interactive_pdf/wc-376_i.pdf

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State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-376i PDF (r.02-08-07)
SOCIAL SECURITY NUMBER: DOB:

ORDER FOR TOTAL DISABILITY w/Second Injury Fund
SSN

CASE NO'S.:

VICINAGE:
FEDERAL EMPLOYER NUMBER NJ REG NUMBER

PETITIONER

NAME:

ATTORNEY FOR PETITIONER

NAME: ADDRESS:

GENDER: ADDRESS (Including County):

MALE

FEMALE

TELEPHONE NUMBER (AREA CODE): APPEARING:

vs
RESPONDENT
NAME: ADDRESS (Including County):

INSURANCE CARRIER

NAME

SELF-INSURED

TPA

CLAIM NUMBER: DATE OF ACCIDENT OR OCCUPATIONAL EXPOSURE: DESCRIBE (Briefly):

NAME:

ATTORNEY FOR RESPONDENT

ADDRESS:

TELEPHONE NUMBER (AREA CODE):

APPEARING:

APPEARING FOR SECOND INJURY FUND:

FUND PETITION FILE DATE:

Upon the proofs presented and the stipulations made, I find and determine the following facts: LAST COMPENSABLE ACCIDENT OR EXPOSURE
WAGES: RATE: Date of last payment of Permanent Compensation by Respondent:

In accordance with the provisions of the New Jersey Workers' Compensation Law (N.J.S.A. 34:15-1 et seq.), I find as follows: Petitioner is totally and permanently disabled as of ____________________________.
Permanent Disability payable by Respondent (Describe Percentages, Nature and extent of Disability, and Members involved):

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-376i PDF (r.02-08-07)

ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 2

CASE NO'S.:

VICINAGE:

AWARD WITHOUT SOCIAL SECURITY OFFSETS
TEMPORARY: PERMANENT: Weeks at $ Weeks at $ =$ =$ less $ less $ paid = Balance due $ paid = Balance due $ Reopener Credit

Voluntary Tender

PAYMENTS DUE FROM RESPONDENT WITH SOCIAL SECURITY OFFSETS
Payments before offset begins Payments with auxiliaries After auxiliaries After offset completed TOTAL PAYMENTS weeks at $ weeks at $ weeks at $ weeks at $ less $ less $ less $ less $ Paid = $ Paid = $ Paid = $ Paid = $ $ + + +

The total and permanent disability is due to the combined effects of the petitioner's previous disabilities and the last compensable accident or occupational exposure and is clearly within the provisions of the above cited statute. Accordingly, it is determined that the petitioner receive benefits from the Second Injury Fund as follows: a. ________ weeks, being the difference between 450 weeks and the ________ weeks of permanent disability compensation previously received. 450 weeks has expired.
b. c. d.

Payable base weekly rate is __________. (If third party or other credits are involved, please explain below. Awarded base weekly rate is $ ___________. Payment to begin upon the expiration of payment of compensation from the last compensation award, but, in any event, not sooner than the date of filing of the petition for benefits from the Second Injury Fund. Commencement date for Fund benefits 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. MEDICAL BILLS (Doctors and/or Institutions):

e.

Petitioner is in receipt of Social Security Disability Benefits and the initial date of entitlement was ____________________. Petitioner's 80% ACE is ___________ and petitioner's initial entitlement was $ ___________including $_____________for auxiliary beneficiaries. Therefore respondent and the Second Injury Fund are entitled to an offset resulting in a rate of $__________ until petitioner's last auxiliary graduates from high school or turns 18 years of age, whichever is later. Thereafter, until the petitioner reaches 62 years of age on __________________ the offset rate shall be $ ______________ . Name of Auxiliary Date of Birth

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-376i PDF (r.02-08-07)

ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 3

CASE NO'S.:

VICINAGE:

The first _______ weeks of permanent disability are to be paid at the full rate of $ ___________ reflecting Petitioner's share of counsel fee and costs. 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 and the Second Injury Fund of this award. The Petitioner shall reimburse the Respondent and the Second Injury Fund for any workers' compensation benefits paid to Petitioner in excess of the 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.

PETITIONER DATA
Date of Last Employment: Occupation: Gross Weekly Wages:

PRE-EXISTING COMPENSABLE DISABILITIES
Date of Injury: Employer Name: Permanent Disability Award: Claim Petition Number:

Description of Injury and Disability:

Hearing Date:

Date of Injury: Employer Name: Permanent Disability Award:

Claim Petition Number:

Description of Injury and Disability:

Hearing Date:

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-376i PDF (r.02-08-07)

ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 4

CASE NO'S.:

VICINAGE:

Date of Injury: Employer Name: Permanent Disability Award:

Claim Petition Number:

Description of Injury and Disability:

Hearing Date:

Date of Injury: Employer Name: Permanent Disability Award:

Claim Petition Number:

Description of Injury and Disability:

Hearing Date:

Date of Injury: Employer Name: Permanent Disability Award:

Claim Petition Number:

Description of Injury and Disability:

Hearing Date:

Date of Injury: Employer Name: Permanent Disability Award:

Claim Petition Number:

Description of Injury and Disability:

Hearing Date:

(Provide like data on additional sheets as required)

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-376i PDF (r.02-08-07)

ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 5

CASE NO'S.:

VICINAGE:

PRE-EXISTING NON-COMPENSABLE DISABILITIES
Date of Onset: Description: Origin (if known): Congenital Accident / Injury

Date of Onset: Description:

Origin (if known): Congenital

Accident / Injury

Date of Onset: Description:

Origin (if known): Congenital

Accident / Injury

Date of Onset: Description:

Origin (if known): Congenital

Accident / Injury

Date of Onset: Description:

Origin (if known): Congenital

Accident / Injury

Date of Onset: Description:

Origin (if known): Congenital

Accident / Injury

Date of Onset: Description:

Origin (if known): Congenital

Accident / Injury

(Provide like data on additional sheets as required)

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-376i PDF (r.02-08-07)

ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 6

CASE NO'S.:

VICINAGE:

PETITIONER DATA
Education (highest level completed): Special Occupational Skills:

Rehabilitation Potential:

Third Party Actions: If third party liability action is pending, provide the name and address of the attorney representing this petitioner if different than the workers' compensation attorney, the defense attorney(s), the case name and docket number. (Respondent and Second Injury Fund reserve their rights under N.J.S.A. 34:15-40)

REMARKS:

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-376i PDF (r.02-08-07)

ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 7
REIMBURSE TAX IDENTIFICATION NUMBER

CASE NO'S.:

VICINAGE:
TOTAL AMT. ALLOWED PAYABLE BY PETITIONER PAYABLE BY RESPONDENT

MEDICAL FEE ALLOWED: (expert and/or testimonial)

ATTORNEY(S) FEE:

STENOGRAPHIC SERVICE:

MISCELLANEOUS FEES: (fill in below)

ORDER FOR CHILD SUPPORT

ADDENDUM ATTACHED

DATE Judge of Compensation
WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY:

Petitioner's Attorney

Respondent's Attorney

Petitioner (where applicable) Deputy Attorney General, Second Injury Fund