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SOCIAL SECURITY NUMBER

1. Claimant’s Name: ______________________________________________________________________

PART C

TO BE COMPLETED BY YOUR EMPLOYER OR COMPANY REPRESENTATIVE

WDS-1(R-2-08)

2. EMPLOYER STATUS

8. BASE WEEKS AND BASE YEAR GROSS

What is your Federal Employer Identification Number: __________________________

WAGES A BASE WEEK is a calendar week in which

the claimant had New Jersey earnings of $145 or more

3. PRIVATE PLAN COVERAGE (NJ approved plan/replaces State Plan coverage)

during the Base Year. The BASE YEAR is the 52

a. Do you have a New Jersey approved Private Plan?

Yes

calendar weeks preceding the week in which the

b. If “Yes”, is claimant covered under this approved Private Plan?

Yes

disability occurred.

4. LAST ACTUAL DAY WORKED before this disability



(do not use payroll week ending dates)

______|______|______

a. Total Number of Base Weeks _________________

(Month

/ Day / Year)

a. Reason for separation from work if other than

b. Total Gross Wages in Base Year ______________

disability ________________________________________________________

Include all wages earned by the claimant

b. Is lack of work: temporary? permanent?

____________________________________________

c. Has claimant returned to work?

Yes



If “Yes”, give date

_______|_____|______

9. REGULAR WEEKLY WAGE $_________________

(Month / Day

/ Year)

d. If the work was intermittent, list dates:_________________________________

5. CONTINUED PAY (do not enter wages earned prior to disability)

10. Weekly wages Indicate below: dates and

a. Have you paid or expect to pay the claimant for any period after the last day of work?

claimant’s GROSS earnings in N.J. employment during

Yes

the listed calendar weeks.

b. If “yes” give dates:

FROM ______|_____|_____ TO _____|_____|_____

Description of

Calendar Week

Gross Wages

(Month / Day / Year)

Calendar Week

Ending Date

c. Amount per week $_____________, if amount varies attach list of dates and amounts.

Week Disability

d. Circle the number that best describes the monies paid in item c.

Began

1. Regular weekly wages and/or sick pay

Week Before

2. Regular vacation (if designated for a specific time period)

Disability

3. Pension

4. Difference between regular weekly wage and disability benefits to be received

2nd Week Before

5. Full salary advanced to effect #4 above

Disability

6. Supplemental benefits or gratuities

3rd Week Before

Note: Items 1, 2, and 3 may reduce benefits to the claimant

Disability

4th Week Before

Disability

6. GOVERNMENT EMPLOYEES (Complete this section)

5th Week Before

a. Payroll number (For N.J. State Employees) _______________________________

Disability

b. Number of earned sick leave days as of the last day worked. _________________

6th Week Before

c. Has the claimant filed for or received Employment Disability Leave

Disability

(SLI)?

Yes

7th Week Before

d. If claimant has applied for or received donated leave, attach dates and amounts on

Disability

a separate sheet of paper.

7. WORKERS’ COMPENSATION LIABILITY

8th Week Before

a. Did the claimant’s disability happen in connection with his/her work or while on your

Disability

premises, or was the disability due in any way to his/her occupation?

Yes

9th Week Before

b. If “Yes”, have you filed or do you intend to file a Workers’ Compensation claim on

Disability

behalf of this claimant?

Yes

10th Week Before

c. If “Yes,” list Workers’ Compensation insurance carrier below:

Disability

TOTAL GROSS WAGES FOR

Name _________________________________ Telephone (

) ________________

ABOVE WEEKS



Address_______________________________________________________________

Are you exempt from FICA tax?

Yes

Policy #___________________________ Claim #______________________________

11. Check the days of the week the employee normally works.

SUN

MON

TUE

WED

THUR

FRI

SAT

Firm Name

and Division # ___________________________________________ I CERTIFY THE INFORMATION GIVEN ABOVE IS CORRECT

Address ________________________________________________ Signed __________________________________ Date________________

City, State, Zip___________________________________________ Print or Type Name ____________________________________________

Mailing Address, If Different_________________________________ Official Title___________________________________________________

FAX No.(

) _______________________ Telephone(

) _____________________E-Mail Address________________________________

Disability Claim Form - State Of New Jersey Department Of Labor And Workforce Development Page 4

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