State of New Jersey Department of Labor and Workforce Development Division of Workers' Compensation PO Box 381 Trenton, New Jersey 08625-0381 WC-366 ( r. 8/26/2015) SOCIAL SECURITY NUMBER: DEPENDENCY CLAIM PETITION NEW FILING Case No.: ______________________________ Vicinage: ______________________________ AMENDED FILING **please enter above only if filing an Amended Claim** TAX IDENTIFICATION NUMBER: SSN Not Available NAME: ATTORNEY FOR PETITIONER NAME: ADDRESS: PETITIONER ADDRESS: DATE OF BIRTH: SEX: TELEPHONE NUMBER: FAX NUMBER: NAME: A GUARDIAN OR OTHER REPRESENTATIVE IS FILING ON BEHALF OF THE PETITIONER. SEE SUPLEMENTAL PAGE FOR DETAILS. vs NAME: IF EMPLOYER IS KNOWN BY DIFFERENT NAME, PLEASE INDICATE HERE: ADDRESS: INSURANCE CARRIER or SELF-INSURED ENTITY ADDRESS: EMPLOYER CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: TO: INDICATE THE STATUS OF THE EMPLOYER: INSURED UNINSURED SELF-INSURED (PRIVATE) SELF-INSURED (GOVT. AGENCY.) NAME: See Supplemental Page for additional carriers INDIVIDUAL CORPORATE OFFICERS OR OTHERS ARE ALSO NAMED AS RESPONDENT(S). SEE SUPPLEMENTAL PAGE FOR DETAILS. SOCIAL SECURITY NUMBER: SSN Not Available DEPENDENTS (at time of death) NAME: (List Petitioner First) 1. 2. 3. 4. DATE OF BIRTH RELATIONSHIP DECEDENT ADDRESS: DATE OF BIRTH: SEX: See Attached For Additional Dependents TO THE DIVISION OF WORKERS' COMPENSATION - INJURY AND EMPLOYMENT DETAILS: Date of Accident or Injury: Date of Death: Where Injury Occurred (incl. town and county): Nature of Injury: Occupational Disease: YES NO How Injury Occurred: If Occupational Disease Give Periods of Exposure: Cause of Death: Date Injury Reported: Gross Wages: $ Burial Expenses: $ Injury Reported to Whom: Wage Period: Payable To: Occupation and Type of Work: Dependency Rate: $ Total Dependency Benefits Paid: $ Demand is hereby made for answers to standard occupational disease interrogatories [N.J.A.C. 12:235-3.8(f)] Demand is hereby made for all records of medical treatment, examinations and diagnostic studies [N.J.A.C. 12:235-3.8 (c)] American LegalNet, Inc. www.FormsWorkFlow.com Was the decedent Medicare eligible or a Medicare beneficiary? Was the decedent eligible for Medicaid benefits at the time of the work injury? Did the decedent become eligible for Medicaid benefits after the work injury? What other facts are there that you believe important: YES YES YES NO NO NO Summary of Changes (Complete only if filing an Amended pleading): Petitioner therefore requests that the Division of Workers' Compensation determine the amount of compensation due Petitioner from said Respondent, pursuant to R.S. 34:15-7 et seq., and that Petitioner may be awarded Petitioner's costs in this proceeding, and such other or further relief as may be proper. ___________________________________________________ Petitioner STATE OF NEW JERSEY COUNTY OF ________________________ Subscribed and sworn or affirmed to before me this _______ day of __________________ , 20_____ ____________________________________________ Please be advised that information collected from the filing of this claim petition 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 Petitioner 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. Page 2 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 DCPsupp 8/26/2015 DEPENDENCY CLAIM PETITION SUPPLEMENTAL PAGE Case No.: ______________________________ Vicinage: ______________________________ GUARDIAN OR REPRESENTATIVE NAME: ADDRESS: RELATIONSHIP TO PETITIONER: ADDITIONAL CARRIERS NAME: ADDRESS: NAME: ADDRESS: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: NAME: ADDRESS: TO: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: NAME: ADDRESS: TO: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: TO: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: TO: INDIVIDUAL CORPORATE OFFICERS/PARTNERS/LLC MEMBERS NAME: ADDRESS: NAME: ADDRESS: NAME: ADDRESS: NAME: ADDRESS: American LegalNet, Inc. www.FormsWorkFlow.com