State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION ORDER FOR TOTAL DISABILITY w/Second Injury Fund WC-376i PDF (r.02-08-07) DOB: NAME: GENDER: MALE FEMALE ADDRESS (Including County): ADDRESS (Including County): NAME: ATTORNEY FOR RESPONDENT VICINAGE: FEDERAL EMPLOYER NUMBER NJ REG NUMBER NAME: ADDRESS: TELEPHONE NUMBER (AREA CODE): APPEARING: NAME: INSURANCE CARRIER RESPONDENT vs SSN ATTORNEY FOR PETITIONER PETITIONER SOCIAL SECURITY NUMBER: CASE NO’S.: ADDRESS: NAME SELF-INSURED TPA CLAIM NUMBER: DATE OF ACCIDENT OR OCCUPATIONAL EXPOSURE: DESCRIBE (Briefly): TELEPHONE NUMBER (AREA CODE): APPEARING: APPEARING FOR SECOND INJURY FUND: FUND PETITION FILE DATE: Upon the proofs presented and the stipulations made, I find and determine the following facts: LAST COMPENSABLE ACCIDENT OR EXPOSURE WAGES: RATE: Date of last payment of Permanent Compensation by Respondent: In accordance with the provisions of the New Jersey Workers’ Compensation Law (N.J.S.A. 34:15-1 et seq.), I find as follows: Petitioner is totally and permanently disabled as of ____________________________. Permanent Disability payable by Respondent (Describe Percentages, Nature and extent of Disability, and Members involved): American LegalNet, Inc. www.FormsWorkflow.com State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC-376i PDF (r.02-08-07) ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 2 CASE NO’S.: VICINAGE: AWARD WITHOUT SOCIAL SECURITY OFFSETS TEMPORARY: Weeks at $ =$ less $ PERMANENT: Weeks at $ =$ less $ paid = Balance due $ paid = Balance due $ Reopener Credit Voluntary Tender PAYMENTS DUE FROM RESPONDENT WITH SOCIAL SECURITY OFFSETS Payments before offset begins weeks at $ less $ Paid = $ + Payments with auxiliaries weeks at $ less $ Paid = $ + + After auxiliaries weeks at $ less $ Paid = $ After offset completed weeks at $ less $ Paid = $ $ TOTAL PAYMENTS The total and permanent disability is due to the combined effects of the petitioner’s previous disabilities and the last compensable accident or occupational exposure and is clearly within the provisions of the above cited statute. Accordingly, it is determined that the petitioner receive benefits from the Second Injury Fund as follows: a. ________ weeks, being the difference between 450 weeks and the ________ weeks of permanent disability compensation previously received. 450 weeks has expired. b. Payable base weekly rate is __________. (If third party or other credits are involved, please explain below. c. Awarded base weekly rate is $ ___________. d. Payment to begin upon the expiration of payment of compensation from the last compensation award, but, in any event, not sooner than the date of filing of the petition for benefits from the Second Injury Fund. Commencement date for Fund benefits is ______________________. e. 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. MEDICAL BILLS (Doctors and/or Institutions): Petitioner is in receipt of Social Security Disability Benefits and the initial date of entitlement was ____________________. Petitioner’s 80% ACE is ___________ and petitioner’s initial entitlement was $ ___________including $_____________for auxiliary beneficiaries. Therefore respondent and the Second Injury Fund are entitled to an offset resulting in a rate of $__________ until petitioner’s last auxiliary graduates from high school or turns 18 years of age, whichever is later. Thereafter, until the petitioner reaches 62 years of age on __________________ the offset rate shall be $ ______________ . Name of Auxiliary Date of Birth American LegalNet, Inc. www.FormsWorkflow.com State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC-376i PDF (r.02-08-07) ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 3 CASE NO’S.: VICINAGE: The first _______ weeks of permanent disability are to be paid at the full rate of $ ___________ reflecting Petitioner’s share of counsel fee and costs. 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 and the Second Injury Fund of this award. The Petitioner shall reimburse the Respondent and the Second Injury Fund for any workers’ compensation benefits paid to Petitioner in excess of the 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. PETITIONER DATA Date of Last Employment: Occupation: Gross Weekly Wages: PRE-EXISTING COMPENSABLE DISABILITIES Date of Injury: Claim Petition Number: Employer Name: Permanent Disability Award: Description of Injury and Disability: Hearing Date: Date of Injury: Claim Petition Number: Employer Name: Permanent Disability Award: Description of Injury and Disability: Hearing Date: American LegalNet, Inc. www.FormsWorkflow.com State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC-376i PDF (r.02-08-07) Date of Injury: ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 4 CASE NO’S.: VICINAGE: Claim Petition Number: Employer Name: Permanent Disability Award: Description of Injury and Disability: Hearing Date: Date of Injury: Claim Petition Number: Employer Name: Permanent Disability Award: Description of Injury and Disability: Hearing Date: Date of Injury: Claim Petition Number: Employer Name: Permanent Disability Award: Description of Injury and Disability: Hearing Date: Date of Injury: Claim Petition Number: Employer Name: Permanent Disability Award: Description of Injury and Disability: Hearing Date: (Provide like data on additional sheets as required) American LegalNet, Inc. www.FormsWorkflow.com State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC-376i PDF (r.02-08-07) ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 5 CASE NO’S.: VICINAGE: PRE-EXISTING NON-COMPENSABLE DISABILITIES Date of Onset: Origin (if known): Congenital Accident / Injury Origin (if known): Congenital Accident / Injury Origin (if known): Congenital Accident / Injury Origin (if known): Congenital Accident / Injury Origin (if known): Congenital Accident / Injury Origin (if known): Congenital Accident / Injury Origin (if known): Congenital Accident / Injury Description: Date of Onset: Description: Date of Onset: Description: Date of Onset: Description: Date of Onset: Description: Date of Onset: Description: Date of Onset: Description: (Provide like data on additional sheets as required) American LegalNet, Inc. www.FormsWorkflow.com State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC-376i PDF (r.02-08-07) ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 6 CASE NO’S.: VICINAGE: PETITIONER DATA Education (highest level completed): Special Occupational Skills: Rehabilitation Potential: Third Party Actions: If third party liability action is pending, provide the name and address of the attorney representing this petitioner if different than the workers’ compensation attorney, the defense attorney(s), the case name and docket number. (Respondent and Second Injury Fund reserve their rights under N.J.S.A. 34:15-40) REMARKS: American LegalNet, Inc. www.FormsWorkflow.com State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC-376i PDF (r.02-08-07) ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 7 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 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) Deputy Attorney General, Second Injury Fund American LegalNet, Inc. www.FormsWorkflow.com