State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-376i (r. 3/19/13) SOCIAL SECURITY NUMBER: DOB: ORDER FOR TOTAL DISABILITY w/Second Injury Fund SSN CASE NO'S.: VICINAGE: FEDERAL EMPLOYER NUMBER NJ REG NUMBER PETITIONER NAME: GENDER: MALE FEMALE 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 CLAIM NUMBER: DATE OF ACCIDENT OR OCCUPATIONAL EXPOSURE: DESCRIBE (Briefly): SELF-INSURED TPA NAME: ATTORNEY FOR RESPONDENT ADDRESS: 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 ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 2 CASE NO'S.: VICINAGE: AWARD WITHOUT SOCIAL SECURITY OFFSETS TEMPORARY: PERMANENT: Weeks at $ Weeks at $ =$ =$ less $ less $ paid = Balance due $ paid = Balance due $ Voluntary Tender Reopener Credit PAYMENTS DUE FROM RESPONDENT WITH SOCIAL SECURITY OFFSETS Payments before offset begins Payments with offset (aux) Payments with offset (no aux) After offset completed TOTAL PAYMENTS weeks at $ weeks at $ weeks at $ weeks at $ less $ less $ less $ less $ Paid = $ Paid = $ Paid = $ Paid = $ $ + + + 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. c. d. Weekly rate prior to offset is Weekly rate subsequent to offset is $ . (If third party offset, please explain on page 6) . 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 . 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): e. 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 ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 3 CASE NO'S.: VICINAGE: The first fee and costs. weeks of permanent disability are to be paid at the full rate of $ reflecting Petitioner's share of counsel 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 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. PETITIONER DATA Date of Last Employment: Occupation: Gross Weekly Wages: PRE-EXISTING COMPENSABLE DISABILITIES Date of Injury: Employer Name: Permanent Disability Award: Claim Petition Number: Description of Injury and Disability: Hearing Date: Date of Injury: Employer Name: Permanent Disability Award: Claim Petition Number: 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 ORDER FOR TOTAL DISABILITY w/Second Injury Fund - Page 4 CASE NO'S.: VICINAGE: Date of Injury: Employer Name: Permanent Disability Award: Claim Petition Number: Description of Injury and Disability: Hearing Date: Date of Injury: Employer Name: Permanent Disability Award: Claim Petition Number: Description of Injury and Disability: Hearing Date: Date of Injury: Employer Name: Permanent Disability Award: Claim Petition Numb