DIVISION OF TEMPORARY DISABILITY INSURANCE
CLAIM FOR DISABILITY BENEFITS (DS-1)
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CLAIMANT RIGHTS AND RESPONSIBILITIES
RULES FOR FILING A CLAIM AND APPEAL RIGHTS
1. It is your responsibility to file this claim form promptly after you stop working due to your disability. Filing
your claim before your last day of work will delay its processing. The law requires that claims must be filed
within 30 days after the beginning of the disability. Benefits may be denied or reduced if the claim is filed
late. If your claim is filed beyond the thirty day period, please use the space provided on the reverse side of
Part A to give your reasons for the late filing.
2. If you disagree with a determination on your claim and wish to appeal, you must do so in writing within ten
days from the date the decision was mailed. You do not need a lawyer at the appeal hearing.
1. Your signature certifies that you understand any misrepresentation of fact or failure to disclose a material
fact may be punishable under the law. This includes any changes to the Medical Certificate or the
Employer’s Statement made by you without authorization by your physician or your employer.
2. You must inform us of any other payments you are receiving such as sick pay or wages, a pension from your
last employer, worker’s compensation benefits, Social Security Disability benefits, or disability benefits
from your employer or union.
3. If you receive a request for continued medical certification (Form P30), you must have your physician
complete and sign the form. You should return it promptly.
4. When you recover or return to work, you must report this date immediately to the Division of Temporary
5. If you are requesting voluntary Federal Income Tax (F.I.T.) deductions to be withheld from your disability
benefits, attach Form W-4S (Request for Federal Income Tax Withholding From Sick Pay) to your claim.
Forms should be obtained from your employer or the Internal Revenue Service.
6. If your home and/or mailing address changes, you must notify the Division of Temporary Disability Insurance,
PO Box 387, Trenton, NJ 08625-0387 immediately in writing. Notification must include your Social Security
Number and signature. Disability checks cannot be forwarded by the Post Office.
If you require any assistance with your claim, call:
• Customer Service Section (609) 292-7060.
• Telecommunication Device for the Deaf (TDD) (609) 292-8319
New Jersey Relay Service: TT user 1-800-852-7899
Voice User: 1-800-852-7897
Division of Temporary Disability Insurance FAX number: (609) 984-4138
For additional information about the Temporary Disability Benefits Program, visit our website at:
(Go to Benefits, Temporary Disability)
NOTE: If your disability is expected to last for one year or longer, you may be eligible for Federal Social
Security Disability Benefits.
Toll Free number for Social Security: 1-800-772-1213.