ORDER FOR TOTAL DISABILITY w/Social Security Offset State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC-375i_pdf (r.02-08-07) VICINAGE: DOB: ADDRESS (Including County): RESPONDENT vs ADDRESS (Including County): ATTORNEY FOR RESPONDENT NAME: ADDRESS: ATTORNEY FOR PETITIONER NAME: SSN INSURANCE CARRIER PETITIONER SOCIAL SECURITY NUMBER: NAME: CASE NO’S.: 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): TELEPHONE NUMBER (AREA CODE): APPEARING: Weekly Wages $ Rate(s) $ / $ IF RE-OPENED PETITION, INDICATE FOR LAST AWARD: DATE:______________________ PERMANENT: $___________________ TEMP: $___________________ 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 w/Social Security Offset CASE NO’S.: Page 2 State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION VICINAGE: WC-375i_pdf (r.02-08-07) AWARD WITHOUT SOCIAL SECURITY OFFSETS TEMPORARY: Weeks at $ =$ less $ PERMANENT: Weeks at $ =$ less $ paid = Balance due $ paid = Balance due $ Voluntary Tender Reopener Credit 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 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 is 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 The first________ weeks of permanent disability are to be paid at the full rate of $ __________ reflecting Petitioner’s share of counsel fee and costs. 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. American LegalNet, Inc. www.FormsWorkflow.com State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION ORDER FOR TOTAL DISABILITY w/Social Security Offset CASE NO’S.: Page 3 VICINAGE: WC-375i_pdf (r.02-08-07) 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. 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) American LegalNet, Inc. www.FormsWorkflow.com