Free PDF - New Jersey


File Size: 66.6 kB
Pages: 1
File Format: PDF
State: New Jersey
Category: Workers Compensation
Word Count: 314 Words, 1,979 Characters
Page Size: 612.12 x 791.759 pts
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http://lwd.dol.state.nj.us/labor/forms_pdfs/wc/pdf/wc(cf)-66(r-2-06).pdf

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State bfNew Jersey Department of Labor and Workforce Development Division ofWorkers' Compensation POBox 381 Trenton, NJ 08625-0381 WC(CF)-66 (R-2-06)

APPLICATION

FOR STAFF USE ONLY

FOR
INFORMAL HEARING

CASE NO: VICINAGE

_ _

o o

NEW AMENDED

I

ORIGINAL INFORMAL CASE

#

SOCIALSECURITYNUMBER
EMPWYEE

EMPLOYER
ADDRESS (Including County)

ADDRESS (Including County)

INSURANCECARRIER

TELEPHONE NUMBER
DATE OF BIRTH

ADDRESS

Name of the Insurance Company can be obtained either from the Employer or by writing to the Compensation Rating and Inspection Bureau 60 Park Place, Newark. New Jersey 07102 (BE SURE TO INCLUDE A SELF-ADDRESSED STAMPED ENVELOPE) Date of Accident

--------D D D D EMPLOYEE (pETITIONER) EMPLOYER INSURANCE CARRIER PETITIONERS ATTORNEY: If checked, please provide Name and Address of Attorney:

Hearing Requested by:

NAME:
ADDRESS:

TELEPHONE NUMBER:
WERE YOU ELIGmLE FOR MEDICAID BENEFITS AT THE TIME OF THE ACCIDENT? D YES D NO DYES D NO DID YOU BECOME ELIGmLE FOR MEDICAID BENEFITS AFTER THE ACCIDENT? YOU ARE ADVISED THAT MEDICAID PAYMENTS RELATED TO THE ACCIDENT ARE TO BE PAID IN ACCORDANCE WITHN.IS.A. 30:14-1, et seq. IMPORTANT: This proceeding will not prevent the Statute of Limitations from expiring. FAILURE TO FILE A FORMAL PETmON within two years of the date of accident or the last payment and / or authorized medical treatment by the employer's insurance carrier can bar any action on a claim filed after that time. TO INSURE IMMEDIATE PROCESSING,
PLEASE COMPLETE THIS FORM IN FULL OR IT WILL BE RETURNED


Date

The Privacy A~ 5 U.S.c. 552a the Social Security A~ 42 U.S.c. 405, and N.J.S.A. 34:15-1 et. seq. authorize the Division of Workers' Compensation to request that the Petitioner supply the Division with his or her Social Security number for record keeping purposes and cross-matches with the Social Security Administration, Workforce New Jersey, Temporary Disability Insurance and any other proper public purpose.