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WDS-1 (R-2-08)

Social Security Number

Claimant’s Name:__________________________________________________

PART A1

CLAIMANT’S AUTHORIZATION AND CERTIFICATION STATEMENTS

MUST BE COMPLETED AND SIGNED BY THE CLAIMANT

1. Please designate a representative to obtain claim information for you if you cannot call this Agency yourself. The Law only permits claim

information to be given to you or your representative.

Representative Name: _________________________________________________________Birth Date: _____________________________

Phone ( ______ )____________________________________ Relationship to Claimant ___________________________________________

2. Certification and Signature I was unable to work during the period for which benefits are claimed and hereby certify that I have

read and understand my benefit rights and responsibilities. I am aware that if any of the foregoing statements made by me are known to be false,

or I knowingly fail to disclose a material fact, I may be subject to penalties, which may include criminal prosecution. You are hereby authorized to

verify my Social Security Account Number, and obtain any medical, employment and Social Security benefit entitlement information that is

necessary to determine my eligibility for benefits.

Sign Here ________________________________________________________________Date_____________________________________

Witness signature if claimant writes an “X” ________________________________________________________________________________

Phone No. (_____)_____________________________ E-Mail Address _______________________________________________________

Note: The NJ Temporary Disability Benefits Program is not a “covered entity” under the Federal Health Information Portability & Accountability Act

(HIPAA). All medical records of the Division, except to the extent necessary for the proper administration of the Temporary Disability Benefits Law

are confidential & are not open to public inspection. The Division protects all records that may reveal the identity of the claimant, or the nature or

cause of the disability and the records may only be used in proceedings arising under the Law.

USE THIS SPACE TO LIST ADDITIONAL EMPLOYERS FOR QUESTION 19.

Name and address:

Period of employment: From __________________ To________________

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

19b. Name and address:

Period of employment: From _________________ To_________________

__________________________________________________

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

USE THIS SPACE TO PROVIDE ANY ADDITIONAL INFORMATION FOR QUESTIONS ON PART A

__________________________________________________________________________________________________________________

If more space is needed, attach an additional sheet of paper. Be sure your Social Security Number appears on all pages.

Disability Claim Form - State Of New Jersey Department Of Labor And Workforce Development Page 2

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