Free State of New Jersey - New Jersey


File Size: 68.8 kB
Pages: 1
Date: March 18, 2009
File Format: PDF
State: New Jersey
Category: Workers Compensation
Author: lawkosn
Word Count: 211 Words, 1,427 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://lwd.dol.state.nj.us/labor/forms_pdfs/wc/pdf/interactive_pdf/wc-100_Dismissal_i.pdf

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

CASE NO'S.:

ORDER FOR DISMISSAL
VICINAGE:
FEDERAL EMPLOYER NUMBER

DATE OF BIRTH: ADDRESS:

ATTORNEY FOR PETITIONER

PETITIONER

NAME: ADDRESS:

vs
RESPONDENT
NAME: ADDRESS:

TELEPHONE NUMBER (AREA CODE): APPEARING: NAME SELF-INSURED TPA

INSURANCE CARRIER

ADDRESS:

NAME:

ATTORNEY FOR RESPONDENT

ADDRESS:

CLAIM NUMBER:

TELEPHONE NUMBER (AREA CODE): APPEARING:

THIS MATTER HAVING COME BEFORE THE COURT ON THIS

DAY OF

,

ORDER FOR DISMISSAL WITHOUT PREJUDICE
Lack of Prosecution pursuant to NJSA 34:15-54, subject to the right to apply to the Division of Workers' Compensation to have the petition reinstated for good cause, within one year from the date of this dismissal. Other:

ORDER FOR DISMISSAL WITH PREJUDICE
Failure to Sustain Burden of Proof Other:
ALLOWANCES
REIMBURSE TAX IDENTIFICATION NUMBER TOTAL AMT. ALLOWED PAYABLE BY PETITIONER PAYABLE BY RESPONDENT

STENOGRAPHIC SERVICE:

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

RESPONDENT'S ATTORNEY

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.