Free PDF - New Jersey

State of New Jersey
Department of Labor and Workforce Development Division of Workers' Compensation P O Box 381 Trenton, New Jersey 08625-0381

REQUEST FOR RECORDS INSPECTION

Requestor Information:
1. Your Name: 2. Company Name: 3. Address: (` Check if new address) 4. Telephone: 5. Your File No: 6. Account No (If previous requestor):

9999999
Search Criteria: 1. Petitioner SS # (required): 3. Petitioner Name (required): 4. Records Requested if NOT Entire Case File(s): 2. Claim Petition # (required):________________________________

9 Exclude above CP# from search. 9 Claim Petition/Answer 9 Medical 9 Closure Documents

The following statement must be completed, signed, dated and submitted to the Division of Workers' Compensation at the address shown above. All copies of documents provided through this request shall adhere to the provisions of N.J.S.A. 34:15-128, et seq as shown on the reverse.

CERTIFICATION

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(Check appropriate box and complete the required information.) I, the undersigned, do hereby certify that I am the claimant, the employer, the insurance carrier or the authorized agent of the claimant, the employer or the insurance carrier and that I am a party to or an authorized agent for a party in a pending workers' compensation case and that use of any records provided through this request will be used solely for purposes directly related to the above requested case. (Copy of agent authorization must be attached.) I, the undersigned, do hereby certify that I am a third party or an authorized agent for a third party directly involved in a workers' compensation case and that any records provided through this request will be used solely for purposes directly related to the above requested case. (Copy of agent authorization must be attached.) I, the undersigned, do hereby certify that I have received specific written release from the claimant in the above requested case allowing me to receive records related to this case, that such written release is attached hereto, and that I have read and agree to the restrictions on my use of such records as prescribed by law. I, the undersigned, do hereby certify that I am an official of a governmental agency and am authorized to request the above case information for purposes of carrying out the recognized purposes of my agency and shall not subsequently disclose any of such information to any person, organization, entity or governmental agency not entitled to receive such information. I, the undersigned, do hereby certify that I am the employer or the authorized agent for the employer and have obtained a signed authorization for the release of workers' compensation records from the prospective employee. The employer has certified that the employee has received an offer of employment and that the information will be used solely in accordance with the provisions of the Americans With Disabilities Act (ADA) and the New Jersey Law Against Discrimination (LAD). (Copy of agent authorization, original signed employee authorization and original signed employer certification must be attached.)

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Signature:__________________________________________________ Printed Name:______________________________________________

Date___________________________________

Delivery of Copies. Unless otherwise indicated above, copies will be issued to the requestor via first class mail upon completion. P.L.1963,c.73 (C.41:1A-1 et seq.) requires that copies of requested documents be made available within seven business days where such documents are currently available and not in storage or archived. Every effort will be made to complete such request and issue resulting copies within seven business days. Where the location or storage condition of requested documents will result in a delay beyond seven business days, the requestor will be notified of such delay and an estimated completion date by first class mail within seven business days of the date of the request. Fees: Copies are certified and are billable at rates of $.75 per page for the first ten pages, $.50 per page for the next ten pages, and $.25 per page thereafter for each workers' compensation case identified meeting the above search criteria. A processing fee of $1.50 per request will be billable in addition to postage for delivery of the results of each rquest.. Billed amounts are due upon presentation. The Division also reserves the right to deny copy services to any requestor where payment for previous copy work remains unpaid for a period of not less than sixty days following delivery and billing for same. A service charge of $25.00 shall also be assessed for any returned payment instrument.

WC-147 (R 7-04)

34:15-128 Limited right to inspect, copy records. 1.a. Notwithstanding any other provisions of the chapter to which this act is a supplement or of any other law, no records maintained by the Division of Workers' Compensation or the Compensation Rating and Inspection Bureau shall be disclosed to any person who seeks disclosure of the records for the purpose of selling or furnishing for a consideration to others information from those records or reports or abstracts or workers' compensation records or work-injury records pertaining to any claimant. No information shall be disclosed from those records to any person not in the division unless: (1) The information is provided in a manner which makes it impossible to identify the claimant; (2) The records are opened for the exclusive purpose of permitting a claimant, employer, insurance carrier or authorized agent of the claimant, employer or insurance carrier to conduct an investigation by or on behalf of the claimant, employer or insurance carrier in connection with any pending workers' compensation case to which the claimant, employer or insurance carrier is a party, and the party seeking access to the records certifies to the division that the information from the records will be used only for the purposes directly related to the case. (3) The records are opened for the exclusive purpose of permitting a third party directly involved in a workers' compensation case, including any workers' compensation lienholders, or an authorized agent of the third party, to conduct an investigation by or on behalf of the third party in connection with the case, and the party seeking access to the records certifies to the division that the information from the records will be used only for the purposes directly related to the case. (4) The records are subpoenaed by the Commissioner of Banking and Insurance pursuant to section 10 of P.L.1983,c.320(C.17:33A-10) or by a court of competent jurisdiction in a civil or criminal proceeding. (5) The division provides the information to another government agency pursuant to law, for a duly recognized purpose of that agency, which agency shall not subsequently disclose any of the information to any person, organization, entity or governmental agency not entitled to receive the information from the Compensation Rating and Inspection Bureau or the Division of Workers' Compensation pursuant to the workers' compensation law, R.S. 34:15-1 et seq.; or (6) The information is information about the claimant requested by the claimant, in which case the division shall disclose the information and the claimant shall not be charged fees in excess of the cost of providing copies of the information. b. Notwithstanding any other provision of law, no information from records maintained by the Compensation Rating and Inspection Bureau pertaining to any work injury or illness or workers' compensation claim shall be disclosed to any business or other member of the public unless the bureau discloses the information in a manner which makes it impossible to identify the claimant. c. Notwithstanding any other provision of law, no information provided by the division to any other governmental agency pursuant to subsection a. of this section shall be disclosed by the agency to any business or other member of the public unless the information is disclosed to the business or other member of the public in a manner which makes it impossible to identiry the claimant. d. Notwithstanding the restrictions on disclosure set forth under subsections a. through c. of this section, a claimant may authorize the release of records of the claimant to a specific person not otherwise authorized to receive the records, by submitting written authorization for the release to the division specifically directing the division to release workers' compensation records to that person. However, no such authorization directing disclosure of records to a prospective employer shall be valid, nor shall an authorization permitting the disclosure of records in connection with assessing fitness or capability for employment be valid, and no disclosure of records shall be made with respect thereto., unless requested pursuant to and consistent with the federal "Americans with Disabilities Act of 1990," 42 U.S.C. s.12101 et seq. And the "Law Against Discrimination," P.L.1945,c.169©.10:5-1 et seq.). It shall be unlawful for any person to consider for the purposes of assessing eligibility for a benefit, or as the basis for an employment-related action, an individual's failure to provide authorization under this subsection.

By state law, requests must be denied when submitted by a person who has been convicted of an indictable offense in New Jersey, any other state, or the United States, who is seeking government records containing personal information pertaining to the person's victim or the victim's family. By law, the Division of Workers' Compensation must notify you that it grants or denies a request for access to its records within 7 business days after the Division has received the request, provided that the record is currently available and not in storage or archived. If the requested record is not currently available or is in storage or archived, the Division will advise you, within 7 business days, of an estimated time that the record will be available. You may agree with the Division to extend the time for granting or denying your request or making records available. You may be denied access to a Division record if your request would substantially disrupt agency operations and the Division is unable to reach an reasonable solution with you. Except as otherwise provided by law or by agreement with the requestor, if the Division fails to respond to you within 7 business days of receiving a written, signed request form, the failure to respond will be considered a denial of your request. Appeal of Denial of Access. A person who is denied access to a government record by the custodian of the record at the option of the requestor, may (1) institute a proceeding to challenge the custodian's decision by filing an action in Superior Court which shall be heard in the vicinage where it is filed by a Superior Court Judge who has been designated to hear such cases because of that judge's knowledge and expertise in matters relating to access to government records; or (2) in lieu of filing an action in Superior Court, file a complaint with the Government Records Council established pursuant to section 8 of P.L. 2001, C.404(C.47:1A-7). The Government Records Council `s address is P O Box 819, Trenton, New Jersey 08625-0819 and its telephone number is (866) 850-0511. The right to institute any proceeding under this section shall be solely that of the requestor. Any such proceedings shall proceed in a summary or expedited manner. The public agency shall have the burden of proof that the denial of access is authorized by law. If it is determined that access has been improperly denied, the court or agency head shall order that access be allowed. A requestor who prevails in any proceeding shall be entitled to a reasonable attorney's fee.