New Jersey Electrical Workers Temporary Disability Benefit Fund Form
ADVERTISEMENT
1
2NEW JERSEY ELECTRICAL WORKERS TEMPORARY DISABILITY BENEFIT FUND
c/o I. E. Shaffer & Co.
PO Box 1028, West Trenton, NJ 08628 ♦ 1-800-792-3666 ♦ 1-609-883-7566 (fax)
This form should be completed by the Employee and Physician immediately after the commencement of disability
and sent to the Employer for benefits under the New Jersey Temporary Disability Benefits Law.
WARNING
INSURANCE FRAUD IS PUNISHABLE UNDER NEW JERSEY LAW BY FINE OR IMPRISONMENT. INDIVIDUALS SUBMITTING
FALSE OR MISLEADING INFORMATION WILL BE PROSECUTED TO THE FULLEST EXTENT OF THE LAW AND WILL BE
SUSPENDED FROM ELIGIBILITY IMMEDIATELY.
EMPLOYEE’S STATEMENT
Member of IBEW Local Union # __________ Social Security # _________________________________________
Name of Employee _________________________________________________ Date of Birth ________________
Street Address ________________________________________________________________________________
City, State, Zip ________________________________________ Telephone (_____) _______________________
Date Accident Occurred or Sickness Began ___________________ Date Last Worked ______________________
Nature of Sickness or Injury _____________________________________________________________________
Were You Injured in the Course of Employment? ____________________________________________________
First Treated On _________________ Where? ______________________________________________________
Dates of Hospitalization ______________________ Name of Hospital ___________________________________
On What Date Did You or Do You Expect To Resume Work? __________________________________________
Certification - I certify that I am not currently eligible for temporary disability benefits under the South Jersey Electrical Workers Temporary
Disability Benefit Plan or any other private temporary disability benefit plan other than the New Jersey Electrical Workers Temporary Disability
Benefit Plan. I authorize my physician to furnish all relevant medical information regarding my disability to the Plan Administrator, I. E. Shaffer
& Co.
Date _________________________ Signature ______________________________________________________
=================================================================================
EMPLOYER’S STATEMENT
Is the Above Information Provided By the Employee Correct to the Best of Your Knowledge? _________________
Please Note Any Errors _________________________________________________________________________
Employee’s
Date Employee
Date Employee
Date of Hire _________________ Last Worked ________________ Notified You of Disability ______________
Is Disability Result of an Occupational Disease or Occupational Injury? __________________________________
Employee’s Gross Earnings Received for Last 8 Weeks Immediately Preceding Week of Disability:
1. $__________ Dates________
2. $__________ Dates_______
3. $__________Dates________
4. $__________ Dates________
5. $__________ Dates_______
6. $__________Dates________
7. $__________ Dates________
8. $__________ Dates_______
IBEW Local Union # Jurisdiction Where Employed at Time Disability Commenced ________________________
Employer _______________________________Tax ID___________________ Private Plan # ________________
Street Address ________________________________________________________________________________
City, State, Zip ________________________________________________ Telephone (_____) ________________
Date __________________________ Signature _____________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Ptd - Claim For Real Property Tax Deduction On Dwelling House Of Qualified New Jersey Resident Senior Citizen, Disabled Person, Or Surviving Spouse
Financial
Form Pd4 - Notice Of Disallowance Of Claim For A Real Property Tax Deduction On Dwelling House Of A New Jersey Resident Senior Citizen, Disabled Person, Or Surviving Spouse
Financial
Form Ptd - Claim For Real Property Tax Deduction On Dwelling House Of Qualified New Jersey Resident Senior Citizen, Disabled Person, Or Surviving Spouse/surviving Civil Union Partner
Financial
Related Categories
Parent category: Legal