Application For Commutation
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Application For Commutation Form. This is a New Jersey form and can be use in Formal Litigation Workers Comp.
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Tags: Application For Commutation, WC-60, New Jersey Workers Comp, Formal Litigation
New Jersey Department of
LaborandWorkforce Development
APPLICATION FOR COMMUTATION
(WC-S-7)
DIVISION OF WORKERS COMPENSATION
WC-60 (R-6-07)
TAX IDENTIFICATION NUMBER
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COUNTY OF RESIDENCE:
ADDRESS
NAME
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DATE FILED
NAME
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C.P.NO.
ADDRESS
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TELEPHONE (Area Code)
TELEPHONE (Area Code)
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NAME
NAME
SELF-INSURED
o NOT-COVERED
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II
COUNTY OF RESIDENCE:
ADDRESS
CLAIM FILE No.
ADDRESS
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rr.
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PLACE OF HEARlNG
TIPE OF HEARING
HEARING OFFICIAL
o Formal
o .Informal
SEX
AGE
MARITAL STATUS
DATE OF
JUDGMENT
DATE OF
ACCIDENT
CITIZEN
o
Dyes
No
AGES
DEPENDENTS NAMES
SEX
REQULAR OCCUP ATION
PRESENT OCCUPAnON
LOCAnON OF PRESENT EMPLOYMENT
WEEllYWAGE
TOTAL FAMILY INCOME
FIXED FAMILY NON-DEFERABLE EXPENSES
$
s
Period of Temporary:
Period of Permanency Paid:
BalanceDue on Award:
s
to
~__
or
% of
or
weeks, or $
_
weeks, or $
_
Amount Requested for Commutation:
_
REASON FOR REQUEST FOR COMMUTATION: (Use additional sheets if necessary)
PLEASE SUBMIT ANY COMMITMENTS TO SUBSTANTIATE YOUR REQUEST.
Signature of Applicant
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(FOR DIVISION OF WORKERS' COMPENSATION USE ONLY)
Report ofInvestigation or Remarks (Attach Rider, if necessary)
(FOR DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT USE ONLY)
D
APPROVED
D
DISAPPROVED
_
JUDGE
Date: - - - - - - - -
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