State of New Jersey Department of Labor and Workforce Development Division of Workers222 Compensation PO Box 381 Trenton, New Jersey 08625-0381 DCPsupp 5/7/2015 DEPENDENCY CLAIM PETITION SUPPLEMENTAL PAGE Case No.: Vicinage: GUARDIAN OR REPRESENTATIVE NAME: ADDRESS: RELATIONSHIP TO PETITIONER: ADDITIONAL CARRIERS NAME: ADDRESS: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: TO: NAME: ADDRESS: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: TO: NAME: ADDRESS: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: TO: NAME: ADDRESS: 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