State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-374i (3/19/13) SOCIAL SECURITY NUMBER: ORDER FOR TOTAL DISABILITY SSN CASE NO'S.: VICINAGE: FEDERAL EMPLOYER NUMBER NJ REG NUMBER PETITIONER NAME: DATE OF BIRTH: ADDRESS (Including County): MEDICARE ELIGIBLE: ATTORNEY FOR PETITIONER NAME:: ADDRESS: YES NO TELEPHONE NUMBER (AREA CODE): APPEARING: vs RESPONDENT NAME: ADDRESS (Including County): INSURANCE CARRIER NAME : SELF-INSURED TPA CLAIM NUMBER; DATE OF ACCIDENT OR OCCUPATIONAL EXPOSURE: DESCRIBE (Briefly): NAME: ATTORNEY FOR RESPONDENT ADDRESS: TELEPHONE NUMBER (AREA CODE): APPEARING: Weekly Wages: $ IF RE-OPENED PETITION, INDICATE FOR LAST AWARD: DATE: PERMANENT: $ TEMP: $ This matter having come before the COURT on this day of Rate(s): $ /$ , : 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 State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-374i (3/19/13) TEMPORARY: PERMANENT: Weeks at $ Weeks at $ ORDER FOR TOTAL DISABILITY Page 2 =$ =$ less $ less $ CASE NO'S.: VICINAGE: 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 The date of Petitioner's Permanent Total disability is as treating physician. . 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 State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-374i (3/19/13) ORDER FOR TOTAL DISABILITY Page 3 REIMBURSE TAX IDENTIFICATION NUMBER CASE NO'S.: VICINAGE: 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) ( IS NOT) ELIGIBLE FOR MEDICARE ADDENDUM ATTACHED 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 State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-168 r. 8/27/2015 CASE NO'S.: CASE EXHIBIT LISTING FOR: PETITIONER RESPONDENT VICINAGE: Judge: Petitioner: Petitioner Attorney: Hearing Date No. ID Ev. Description Respondent: Respondent Attorney: Retained Court Atty. Reporter Page of American LegalNet, Inc. www.FormsWorkFlow.com