Order For Dismissal
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Order For Dismissal Form. This is a New Jersey form and can be use in Settlement Workers Comp.
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Tags: Order For Dismissal, WC-100, New Jersey Workers Comp, Settlement
State of New Jersey
Department of Labor and Workforce Development
DIVISION OF WORKERS’ COMPENSATION
CASE NO’S.:
ORDER FOR DISMISSAL
WC-100-Dismissal PDF (r. 3/18/09)
VICINAGE:
FEDERAL EMPLOYER NUMBER
ATTORNEY FOR PETITIONER
PETITIONER
NAME:
DATE OF BIRTH:
ADDRESS:
NAME:
ADDRESS:
NAME:
ATTORNEY FOR
RESPONDENT
ADDRESS:
TELEPHONE NUMBER (AREA CODE):
APPEARING:
NAME
INSURANCE
CARRIER
RESPONDENT
vs
NAME:
ADDRESS:
SELF-INSURED
TPA
ADDRESS:
CLAIM NUMBER:
TELEPHONE NUMBER (AREA CODE):
APPEARING:
THIS MATTER HAVING COME BEFORE THE COURT ON THIS
DAY OF
,
ORDER FOR DISMISSAL WITHOUT PREJUDICE
Lack of Prosecution pursuant to NJSA 34:15-54, subject to the right to apply to the Division of Workers'
Compensation to have the petition reinstated for good cause, within one year from the date of this dismissal.
Other:
ORDER FOR DISMISSAL WITH PREJUDICE
Failure to Sustain Burden of Proof
Other:
ALLOWANCES
REIMBURSE
TAX IDENTIFICATION
NUMBER
TOTAL AMT.
ALLOWED
PAYABLE BY
PETITIONER
PAYABLE BY
RESPONDENT
STENOGRAPHIC SERVICE:
WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND
ACKNOWLEDGE RECEIPT OF COPY:
PETITIONER’S ATTORNEY
JUDGE OF COMPENSATION
DATE
PETITIONER (where applicable)
JUDGE’S NAME
RESPONDENT’S ATTORNEY
THE ORIGINAL OF THIS DOCUMENT, SIGNED BY THE JUDGE OF
COMPENSATION, WILL BE MAINTAINED ON FILE IN THE DIVISION
OF WORKERS’ COMPENSATION, PURSUANT TO
N.J.S.A. 34:15-121 et seq.
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