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READ THE FOLLOWING INSTRUCTIONS BEFORE COMPLETING THE ATTACHED FORM,

CLAIM FOR DISABILITY BENEFITS – DS-1

1. Complete both sides of the claimant’s portion of this form (Part A & A1.) YOU ARE RESPONSIBLE

for having Part B completed by your doctor and Part C by your last employer. If you have worked for more

than one employer during the past year, you may copy Part C for completion by the other employer(s) to avoid

processing delays. Any missing or incorrect entries on this form will delay processing of your claim. If

you cannot have Parts B and/or C completed timely, complete Part A and A1 and return the application as

soon as possible.

REMEMBER SENDING IN SEPARATE PARTS OF THE APPLICATION

WILL DELAY YOUR CLAIM. NOTE: IF YOU CHOOSE TO FAX THIS

FORM TO OUR OFFICE, BE SURE TO COPY THE BACK SIDE OF EACH

PAGE AND FAX ALL FOUR PAGES AND ANY OTHER ATTACHMENTS.

MAIL OR FAX PART A, PART A1, PART B AND PART C TOGETHER TO:

Division of Temporary Disability Insurance

PO Box 387

Trenton, NJ 08625-0387

FAX No: (609) 984-4138

2. Read all questions carefully! Print or write clearly since this information is used to determine your right to

benefits. If you need any assistance in completing this form, please call the Customer Service Section in

Trenton at (609) 292-7060 and hold for an agent.

3. BE SURE TO WRITE YOUR SOCIAL SECURITY NUMBER AND NAME ON EACH PORTION OF

YOUR CLAIM.

Instructions For Part A and A1 – Claimant’s Statement – Please complete all questions

Items 1, 4 & 6

Include your full name and complete address (this information is required). If your mailing

address is different than your home address, be sure to complete Item 6.

Please print or type your Social Security Number CLEARLY. An incorrect or illegible

Item 3

number will cause a delay in processing your claim.

You must complete this item. If your answer to this question is “No,” you must complete

Item 9

Items 10 and 11 and give your country of origin.

Please give exact dates. Remember to include the dates of any Emergency Room care you

Items 12 –15

may have received for this disability. If available, provide proof of emergency room care.

List the name and address of the physician who treated you for this disability. You must be

Item 18

under the care of a legally licensed physician, dentist, optometrist, podiatrist, practicing

psychologist, chiropractor or advanced practice nurse. If you have been treated by more

than one physician, use the additional space provided on the reverse side of Part A to list

their names and addresses.

Starting with your most recent employer, list all employers, including those for whom you

Item 19

worked part-time, for the last 18 months. If you had more than two employers, list the

others with the dates you worked in the space provided on Part A1. Give business names

and addresses as they appear on your pay envelopes, pay checks, employers’ stationery or

as listed in the telephone book.

Part A1

In the event that you are unable to telephone our agency, you may designate a

Item 1

representative in this space to obtain information on your behalf. If there is no one listed,

only YOU will be able to obtain information on your claim from this agency.

Item 2

Sign and date the claim form. Include your telephone number.

Important: We suggest that you keep a copy of the completed claim form for your records.

Form Ds-1 - Claim For Disability Benefits - New Jersey Department Of Labor And Workforce Development Page 2

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