Addendum To Order For Total Disability
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Addendum To Order For Total Disability Form. This is a New Jersey form and can be use in Settlement Workers Comp.
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Tags: Addendum To Order For Total Disability, WC-377, New Jersey Workers Comp, Settlement
State of New Jersey
Department of Labor and Workforce Development
DIVISION OF WORKERS’ COMPENSATION
WC-377i (r.08-14-09)
ADDENDUM TO
ORDER FOR
TOTAL DISABILITY
CASE NO’S.:
VICINAGE:
Case Name:
Petitioner’s Social Security Number:
Petitioner is in receipt of a government ordinary disability retirement pension. The date of retirement was _______________. The
initial retirement benefit was $ ____________ per month. The pension portion of the retirement benefit was $ ___________ per month.
The annuity portion of the retirement benefit was $ ____________ per month. The respondent and/or the Second Injury Fund is/are
entitled to an offset for this benefit. Based upon the last compensable injury and the reasons for the ordinary disability retirement, the
offset shall be _______ % of the pension portion of the retirement benefit, or $ ____________ per week resulting in a weekly rate of
$ ________.
Other:
DATE
JUDGE OF COMPENSATION
WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS
ORDER AND ACKNOWLEDGE RECEIPT OF COPY:
PETITIONER’S ATTORNEY
RESPONDENT’S ATTORNEY
PETITIONER (where applicable)
DEPUTY ATTORNEY GENERAL
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