Second Injury Fund Information Review Sheet
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Second Injury Fund Information Review Sheet Form. This is a New Jersey form and can be use in Formal Litigation Workers Comp.
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Tags: Second Injury Fund Information Review Sheet, WC-380, New Jersey Workers Comp, Formal Litigation
Second Injury Fund Information Review
Case Name:
Claim Petition Number(s):
Wage:
Rate:
DOB:
Last Day of Work:
Last Day on Payroll (if different):
IF ACCIDENT
Date of Accident:
Injuries to:
IF EXPOSURE
Last Exposure on:
Injuries to:
Amount of Temporary Disability Paid:
$
Additional Temporary Disability Claimed:
$
Medicals To Be Paid:
From:
To:
From:
To:
Check All That Apply:
Voluntary Tender, (if checked) Amount: $
Medicare Entitled
Conditional Payment Info. Requested
SSD Recipient (if checked):
1. Date of Entitlement:
2. 80% ACE
$
3. Initial Entitlement $
Includes Auxiliaries:
yes
no
Third Party Action (if checked): Recovery: $
Public Pension (if checked): Type of Pension:
List Treating Doctors and Hospitals (Including Pre-Existing):
Pre-existing Disabilities and Compensation Awards:
Petitioner Evaluating Doctors and Estimates:
Respondent Evaluating Doctors and Estimates:
WC-380 (6-08)
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