Claim For Continued Benefits - Ddu Form

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CLAIM FOR CONTINUED BENEFITS - DDU
Name:
Division of Temporary Disability Insurance
Social Security Number:
Disability During Unemployment
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PO Box 956
Date of Claim:
Trenton, NJ 08625-0956
You and your doctor must complete this form and return it to the address listed above if you
continue to be unable to perform any work after the last day for which you were awarded disability
benefits.
My name has changed to:_____________________________________________
My new mailing address is: Street_______________________________________ Apt #_________
City_________________________State__________Zip Code________
I was/will be unable to do any work after the last day for which I was awarded disability benefits. I hereby claim benefits for my continued
disability. I certify that I continue to meet all eligibility requirements of the Unemployment Compensation Law except for the ability to work
as certified below by my doctor. I also certify that I have not claimed or received benefits or payments from any other source(s) for any
period for which I have claimed temporary disability benefits. I understand that if any of the foregoing statements made by me are known to
be false, or I willingly fail to disclose a material fact, I may be subject to penalties which may include criminal prosecution.
________________________________________
__________________________
(Claimant’s Signature)
(Date)
MEDICAL CERTIFICATION
What are your objective physical findings?__________________________________________________
What is the current diagnosis?____________________________________________________________
What has the treatment been to date?_______________________________________________________
List all dates of treatment:______________________________Date of Next Appointment: ___________
Is the claimant able to do any work?
Yes
No. If Yes, as of what date?_______________________
If No, Please complete below:
PROGNOSIS/RECOVERY DATE: ___________________ Please give estimated date. Do not use
“Unknown”, “Indefinite,” “Undetermined.” Prognosis may be revised later if necessary.
If claimant is pregnant, please provide: Date pregnancy terminated:______________________________
Normal Delivery
C-Section
Other
Complications, if any___________________________________
Physician’s Name and Degree ____________________________________________________________
(Please Print)
Address_______________________________________________Telephone No (______)____________
License No. and State________________________Medical Specialty_____________________________
Physician’s Original Signature_______________________________Date________________________

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