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.