Disability Claim Form - State Of New Jersey Department Of Labor And Workforce Development

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State Disability Claims
P.O. Box 14332
Lexington, KY 40512
Telephone # 1-800-268-2525 Fax # 610-807-2953 Email:
STATE OF NEW JERSEY – DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF TEMPORARY DISABILITY INSURANCE
PART A
INFORMATION TO BE COMPLETED BY THE CLAIMANT – Print or Type WDS-1(R-2-08)
Policy #
1. Name: Last First Middle
2. Birth Date
3.Social Security Number
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4. Home Address – required (Street, Apt #, City, State, Zip Code)
5. County
6. Mailing Address – if different (Street, Apt #, City State, Zip Code)
7.
Male
8. Occupation
Female
9. Are you a citizen of the United States?
Yes
No
10. Alien Reg. No.
11. Work Authorization
If NO, answer #10 & 11 and give country of origin: ________________
From __________ To _________
12a. What was the last day that you actually worked before your disability began?
Month
Day
Year
12b. Reason for separation:
Illness/Accident/Maternity
Terminated
Quit
13. What was the first day you were unable to work due to present disability:
(Include Saturday, Sunday, or Holiday) Do not list future dates
14. If you have recovered or have a possible return to work date from this disability, list date:
Actual
Possible
15. Date(s) of emergency room care:__________________ or hospitalization: From ___________________ To ___________________
Month/Day/Year
Month/Day/Year
Month/Day/Year
16. Describe your disability (How, when, where it happened) ________________________________________________________________
____________________________________________________________________________________________________________________
17. Was this injury/illness caused by your job?
Yes or
No (This question must be answered.) If Yes, date of work related
injury/illness:_________________ Was your employer notified that your injury was caused by your job?
Yes or
No
18. Identify the physician or hospital treating you for this disability: Name: _________________________________________________________
Address: __________________________________________________________________ Telephone: (_____)__________________________
Employment Information – Beginning with your last employer, list all employment (both full and part-time) in the past 18 months. If you had
more than 2 employers, list the remaining employers on the reverse side of this form in the space provided.
19a. Name and address of your most recent employer:
Period of employment: From ________________ To________________
month/day/year
month/day/year
_______________________________________________________
Work
_______________________________________________________
Telephone: ____________________ Location ____________________
City
State
(Street)
(City)
(State)
(Zip)
Occupation: ________________________________
Full time
Part time
Union _________________ Division____________________
Check the days of the week you normally work.
SUN
MON
TUE
WED
THUR
FRI
SAT
19b. Name and address:
Period of employment: From ________________ To________________
______________________________________________________
month/day/year
month/day/year
Work
______________________________________________________
Telephone: ____________________ Location _____________________
(Street)
(City)
(State)
(Zip)
City
State
Occupation: ________________________________
Full time
Part time
Union ___________________Division___________________
Check the days of the week you normally work.
SUN
MON
TUE
WED
THUR
FRI
SAT
20. Other Benefits – You Must Answer Each Question Listed Below For the Period of Disability Covered By This Claim:
a. Have you worked after your disability began? (Including self-employment)
Yes
No
b. Have you been receiving sick or vacation pay?
Yes
No
c. Have you been involved in a labor dispute?
Yes
No
21. Since your last day of work have you received, claimed or applied for:
a. Federal Social Security Disability Benefits?
Yes
No
b. Pension benefits from your most recent employer?
Yes
No
c. Temporary Disability Benefits from another State?
Yes
No
d. Any other disability benefits provided by your employer or union?
Yes
No
e. Unemployment Insurance Benefits?
Yes
No
BE SURE TO COMPLETE AND SIGN PART A1

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