State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-375i (r. 3/19/13) SOCIAL SECURITY NUMBER: ORDER FOR TOTAL DISABILITY w/Social Security Offset SSN CASE NO'S.: VICINAGE: FEDERAL EMPLOYER NUMBER NJ REG NUMBER NAME: ATTORNEY FOR PETITIONER NAME:: ADDRESS: PETITIONER DATE OF BIRTH: ADDRESS (Including County): MEDICARE ELIGIBLE: 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-375i ORDER FOR TOTAL DISABILITY w/Social Security Offset 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) weeks at $ weeks at $ weeks at $ weeks at $ less $ less $ less $ less $ Paid = $ Paid = $ Paid = $ Paid = $ $ + + + After offset completed 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 the from high school or turns 18 years of age, whichever is later. Thereafter, until the petitioner reaches 62 years of age on offset rate shall be $ . Name of Auxiliary Date of Birth The first fee and costs. weeks of permanent disability are to be paid at the full rate of $ reflecting Petitioner's share of counsel 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 WC-375i ORDER FOR TOTAL DISABILITY w/Social Security Offset Page 3 . CASE NO'S.: VICINAGE: 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 MEDICAL FEE ALLOWED: (expert and/or testimonial) TAX IDENTIFICATION NUMBER TOTAL AMT. ALLOWED PAYABLE BY PETITIONER PAYABLE BY RESPONDENT 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 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