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Order (Judgment Or Approving Settlement) With Case Exhibit Listing Form. This is a New Jersey form and can be use in Settlement Workers Comp.
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Tags: Order (Judgment Or Approving Settlement) With Case Exhibit Listing, WC(DO)-100, New Jersey Workers Comp, Settlement
ORDER
State of New Jersey
Department of Labor and Workforce Development
DIVISION OF WORKERS’ COMPENSATION
JUDGMENT
WC(DO)-100 PDF (r. 8/14/09)
APPROVING SETTLEMENT
DATE OF BIRTH:
ADDRESS:
NAME:
ADDRESS:
NAME:
ADDRESS:
TELEPHONE NUMBER (AREA CODE):
APPEARING:
NAME
INSURANCE
CARRIER
RESPONDENT
vs
NAME:
ATTORNEY FOR
RESPONDENT
VICINAGE:
FEDERAL EMPLOYER NUMBER
ATTORNEY FOR PETITIONER
PETITIONER
NAME:
CASE NO’S.:
ADDRESS:
SELF-INSURED
TPA
ADDRESS:
CLAIM NUMBER:
DATE OF ACCIDENT OR OCCUPATIONAL EXPOSURE:
TELEPHONE NUMBER (AREA CODE):
DESCRIBE (Briefly):
APPEARING:
Weekly Wages :
$
Rate(s):
$
/
$
IF RE-OPENED PETITION, INDICATE FOR LAST AWARD:
Date:
Permanent Paid:
$
THIS MATTER HAVING COME BEFORE THE COURT ON THIS
Temporary Paid:
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 indicated on Page 2.
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 indicated on page 2.
PERMANENT DISABILITY (Describe Percentages below followed by the Nature and Extent of Injury and Members involved):
% of
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CASE NO’S.:
ORDER
State of New Jersey
Department of Labor and Workforce Development
DIVISION OF WORKERS’ COMPENSATION
JUDGMENT
WC(DO)-100 PDF (r. 8/14/09)
APPROVING SETTLEMENT
DISABILITY AWARDED:
TEMPORARY:
weeks at $
=$
less $
PERMANENT:
weeks at $
=$
VICINAGE:
less $
paid = Balance due $
paid = Balance due $
Voluntary Tender
Reopener Credit
N.J.S.A. 34:15-40
MEDICAL BILLS (Doctors and/or Institutions) AND/OR MISCELLANEOUS INFORMATION:
ORDER FOR CHILD SUPPORT
ALLOWANCES
ADDENDUM ATTACHED
REIMBURSE
TAX IDENTIFICATION
NUMBER
TOTAL AMT.
ALLOWED
PAYABLE BY
PETITIONER
PAYABLE BY
RESPONDENT
MEDICAL FEE ALLOWED: (report and/or testimony)
INTERPRETER:
ATTORNEY(S) FEE:
STENOGRAPHIC SERVICE
MISCELLANEOUS FEES: (list below)
WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND
ACKNOWLEDGE RECEIPT OF COPY:
PETITIONER’S ATTORNEY
JUDGE OF COMPENSATION
PETITIONER (where applicable)
JUDGE’S NAME
RESPONDENT’S ATTORNEY
DATE
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.
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CASE NO’S.:
State of New Jersey
Department of Labor and Workforce Development
DIVISION OF WORKERS’ COMPENSATION
WC-168 r. 3/18/09
CASE EXHIBIT LISTING
FOR:
PETITIONER
RESPONDENT
VICINAGE:
Judge:
Petitioner:
Respondent:
Petitioner Attorney:
Respondent Attorney:
Hearing Date
No.
ID
Ev.
Description
Retained
Court Atty.
Page
Reporter
of
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