State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC(DO)-100 Generic i (r.7/10/2013) NAME: FEDERAL EMPLOYER NUMBER CASE NO'S.: VICINAGE: ATTORNEY FOR PETITIONER PETITIONER DATE OF BIRTH: MEDICARE ELIGIBLE: ADDRESS: NAME: YES NO ADDRESS: vs RESPONDENT NAME: TELEPHONE NUMBER (AREA CODE): APPEARING: ADDRESS: NAME SELF-INSURED TPA INSURANCE CARRIER ADDRESS: NAME: ATTORNEY FOR RESPONDENT ADDRESS: CLAIM NUMBER: DATE OF ACCIDENT OR OCCUPATIONAL EXPOSURE: TELEPHONE NUMBER (AREA CODE): DESCRIBE (Briefly): APPEARING: This matter having come before the COURT on this IT IS ORDERED day of , ALLOWANCES MEDICAL FEE ALLOWED: (report and/or testimony) REIMBURSE TAX IDENTIFICATION NUMBER TOTAL AMT. ALLOWED PAYABLE BY PETITIONER PAYABLE BY RESPONDENT ATTORNEY(S) FEE: STENOGRAPHIC SERVICE: WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY: PETITIONER'S ATTORNEY JUDGE OF COMPENSATION DATE PETITIONER (where applicable) RESPONDENT'S ATTORNEY JUDGE'S NAME THE ORIGINAL OF THIS DOCUMENT, SIGNED BY THE JUDGE OF COMPENSATION, WILL BE MAINTAINED ON FILE IN THE DIVISION OF WORKERS' COMPENSATION, PURSUANT TO N.J.S.A. 34:15-121 et. seq. American LegalNet, Inc. www.FormsWorkFlow.com