Order For Total Disability Form. This is a New Jersey form and can be use in Settlement Workers Comp.
Tags: Order For Total Disability, WC-374, New Jersey Workers Comp, Settlement
State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION CASE NO’S.: ORDER FOR TOTAL DISABILITY WC-374i (8-14-09) VICINAGE: SSN ATTORNEY FOR PETITIONER PETITIONER SOCIAL SECURITY NUMBER: NAME: MEDICARE ELIGIBLE: DATE OF BIRTH: YES NO ADDRESS (Including County): NAME: ADDRESS (Including County): INSURANCE CARRIER RESPONDENT vs ATTORNEY FOR RESPONDENT NAME: FEDERAL EMPLOYER NUMBER NJ REG NUMBER NAME:: ADDRESS: TELEPHONE NUMBER (AREA CODE): APPEARING: NAME : SELF-INSURED TPA CLAIM NUMBER; DATE OF ACCIDENT OR OCCUPATIONAL EXPOSURE: DESCRIBE (Briefly): ADDRESS: TELEPHONE NUMBER (AREA CODE): APPEARING: Weekly Wages: $ Rate(s): $ / $ IF RE-OPENED PETITION, INDICATE FOR LAST AWARD: DATE: TEMP: $ PERMANENT: $ This matter having come before the COURT on this day of , : ORDER FOR JUDGMENT It appearing that the Petitioner suffered a compensable injury on the above mentioned date while in the employ of respondent; It is Ordered and Adjudged that Petitioner be awarded compensation benefits, payable as set forth below. ORDER APPROVING SETTLEMENT The parties having settled the matter and a finding by the Court having been made that the terms of the settlement are fair and just; It is Ordered that this settlement be approved and the petitioner be paid as set forth below. PERMANENT DISABILITY: American LegalNet, Inc. www.FormsWorkFlow.com ORDER FOR TOTAL DISABILITY Page 2 State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC-374i (8-14-09) CASE NO’S.: VICINAGE: TEMPORARY: Weeks at $ =$ less $ PERMANENT: Weeks at $ =$ less $ paid = Balance due $ paid = Balance due $ Voluntary Tender Reopener Credit MEDICAL BILLS (Doctors and/or Institutions): An application for Social Security Disability Benefits and / or Government Ordinary Disability Pension is pending is on appeal has not been filed. Should Petitioner be awarded Social Security Disability Benefits and / or Government Ordinary Disability Pension, Petitioner shall immediately notify the Respondent of this award. The Petitioner shall reimburse the Respondent for any workers’ compensation benefits paid to Petitioner in excess of the statutory offset rate during the period of time Petitioner has received Social Security Disability benefits or Government Ordinary Disability Pension. In the event there is a change in the number or status of the auxiliary beneficiaries while Petitioner is receiving Workers’ Compensation benefits, Petitioner shall immediately notify the Respondent. I further Order that Respondent furnish the Petitioner such medical attention, prosthesis, and medical supplies as the condition of the Petitioner may require. Should any emergency arise, necessitating immediate medical attention for the Petitioner, notice and request to Respondent shall not be necessary. Respondent authorizes as treating physician. The date of Petitioner’s Permanent Total disability is . On which is the expiration of the 450 week period, benefits to continue in accordance with the provision of N.J.S.A. 34:15-12(b) as amended. Pursuant to N.J.S.A. 34:15-12(b), petitioner will be referred to the Division of Vocational Rehabilitation Services for evaluation and services prior to the expiration of 450 weeks from the date of Total Permanent Disability. American LegalNet, Inc. www.FormsWorkFlow.com ORDER FOR TOTAL DISABILITY Page 3 State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC-374i (8-14-09) CASE NO’S.: VICINAGE: REIMBURSE TAX IDENTIFICATION NUMBER TOTAL AMT. ALLOWED PAYABLE BY PETITIONER PAYABLE BY RESPONDENT MEDICAL FEE ALLOWED: (expert and/or testimonial) ATTORNEY(S) FEE: STENOGRAPHIC SERVICE: MISCELLANEOUS FEES: (fill in below) ORDER FOR CHILD SUPPORT MEDICARE ELIGIBILITY: PETITIONER ( IS) ( ADDENDUM ATTACHED IS NOT) ELIGIBLE FOR MEDICARE 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) American LegalNet, Inc. www.FormsWorkFlow.com