State of New Jersey Department of Labor and Workforce Development Division of Workers' Compensation PO Box 381 Trenton, New Jersey 08625-0381 WC-368 r.8/26/2015 SOCIAL SECURITY NUMBER: NAME: APPLICATION FOR REVIEW OR MODIFICATION OF FORMAL AWARD Case No.: ______________________________ Vicinage: ______________________________ **Case Number Required** ORIGINAL AMENDED FILING TAX IDENTIFICATION NUMBER: NAME: ADDRESS: ADDRESS: DATE OF BIRTH: SEX: ATTORNEY FOR PETITIONER PETITIONER TELEPHONE NUMBER: FAX NUMBER: RESPONDENT A guardian or other representative is filing on behalf of the petitioner. See additional page for details. vs NAME: NAME: ADDRESS: INSURANCE CARRIER / TPA ADDRESS: CARRIER CLAIM NUMBER: If uninsured, individual corporate officers, or others, are also named as respondent(s). See Supplemental Page for details. See Supplemental Page for additional carriers TO THE DIVISION OF WORKERS' COMPENSATION: _______________________________________________ (Name of Petitioner or Respondent), pursuant to N.J.S.A. 34:15-27 seeks modification and review of the award entered on ____________________________, for the following reasons: As to Claim Petitioner: Date of Injury: Date of Last Comp. Pd: Present Employment Status: Claim Petitions filed since last award: See Attached For Additional Information This is the ____________ Application for Review or Modification of this award. (Number) Demand is hereby made for all records of medical treatment, examinations and diagnostic studies. [N.J.A.C. 12:235-3.8 (c)] ARE YOU MEDICARE ELIGIBLE OR A MEDICARE BENEFICIARY? WERE YOU ELIGIBLE FOR MEDICAID BENEFITS AT THE TIME OF THE WORK INJURY? DID YOU BECOME ELIGIBLE FOR MEDICAID BENEFITS AFTER THE WORK INJURY? Summary of Changes (Complete only if filing an Amended pleading): YES YES YES NO NO NO STATE OF NEW JERSEY, COUNTY OF ________________________ Subscribed and sworn or affirmed to before me this _______ day of __________________ , __________ ____________________________________________ _____________________________________________________ Applicant Please be advised that information collected from the filing of this Application for Review or Modification of Formal Award may be used by the Division of Workers' Compensation for record keeping, record access/distribution, and case scheduling purposes. Petitions filed with the Division are public documents and may be inspected and copied except where prohibited by Section 34:15-128 of the Workers' Compensation Statute. The Privacy Act, 5 U.S.C. §552a, the Social Security Act, 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 Applicant 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. DIVISION OF WORKERS' COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com State of New Jersey Department of Labor and Workforce Development Division of Workers' Compensation PO Box 381 Trenton, New Jersey 08625-0381 WC-368supp r. 8/26/2015 APPLICATION FOR REVIEW OR MODIFICATION OF FORMAL AWARD SUPPLEMENTAL PAGE Case No.: ______________________________ Vicinage: ______________________________ ADDITIONAL CARRIERS NAME: ADDRESS: NAME: ADDRESS: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE:: FROM: TO: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE:: FROM: TO: GUARDIAN OR REPRESENTATIVE NAME: ADDRESS: RELATIONSHIP TO PETITIONER: INDIVIDUAL CORPORATE OFFICERS/PARTNERS/LLC MEMBERS NAME: ADDRESS: NAME: ADDRESS: American LegalNet, Inc. www.FormsWorkFlow.com