Free State of New Jersey - New Jersey

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-375i_pdf (r.02-08-07)
SOCIAL SECURITY NUMBER: DOB:

ORDER FOR TOTAL DISABILITY w/Social Security Offset
SSN

CASE NO'S.:

VICINAGE:
FEDERAL EMPLOYER NUMBER NJ REG NUMBER

NAME: ADDRESS (Including County):

ATTORNEY FOR PETITIONER

PETITIONER

NAME:: ADDRESS:

vs
RESPONDENT
NAME: ADDRESS (Including County):

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

INSURANCE CARRIER

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

NAME:

ATTORNEY FOR RESPONDENT

ADDRESS:

TELEPHONE NUMBER (AREA CODE): APPEARING:

Weekly Wages $

Rate(s)

$

/ $

IF RE-OPENED PETITION, INDICATE FOR LAST AWARD: DATE:______________________ PERMANENT: $___________________ TEMP: $___________________
2007 This matter having come before the COURT on this ____ day of ______________, _______.

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 set forth below. 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 set forth below. PERMANENT DISABILITY:

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-375i_pdf (r.02-08-07)

ORDER FOR TOTAL DISABILITY w/Social Security Offset
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 $ Voluntary Tender Reopener Credit

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 = $ $ + + +

MEDICAL BILLS (Doctors and/or Institutions):

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 is 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

The first________ weeks of permanent disability are to be paid at the full rate of $ __________ reflecting Petitioner's share of counsel fee and costs. 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.

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-375i_pdf (r.02-08-07)

ORDER FOR TOTAL DISABILITY w/Social Security Offset
Page 3

CASE NO'S.:

VICINAGE:

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.
REIMBURSE MEDICAL FEE ALLOWED: (expert and/or testimonial) TAX IDENTIFICATION NUMBER TOTAL AMT. ALLOWED PAYABLE BY PETITIONER PAYABLE BY RESPONDENT

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)