Form Ds-1 - Claim For Disability Benefits - New Jersey Department Of Labor And Workforce Development Page 3
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6STATE OF NEW JERSEY – DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF TEMPORARY DISABILITY INSURANCE
PART A
INFORMATION TO BE COMPLETED BY THE CLAIMANT – Print or Type
WDS-1(R-1-07)
1. Name: Last
First
Middle
2. Birth Date
3.Social Security Number
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4. Home Address – required (Street, Apt #, City, State, Zip Code)
5. County
6. Mailing Address – if different (Street, Apt #, City State, Zip Code)
7.Male
8. Occupation
Female
9. Are you a citizen of the United States? Yes
No
10. Alien Reg. No.
11. Work Authorization
If NO, answer #10 & 11 and give country of origin: ______________
From ___________ To ___________
Month
Day
Year
12a. What was the last day that you actually worked before your disability began?
12b. Reason for separation:
Illness/Accident/Maternity
Terminated
Quit
13. What was the first day you were unable to work due to present disability:
(Include Saturday, Sunday, or Holiday) Do not list future dates
14. If you have recovered or returned to work from this disability, list date:
(Do not use dates in the future)
15. Date(s) of emergency room care:__________________ or hospitalization: From ___________________ To ___________________
Month/Day/Year
Month/Day/Year
Month/Day/Year
16. Describe your disability (How, when, where it happened) _________________________________________________________
________________________________________________________________________________________________________________________________________
17. Was this injury/illness caused by your job?
Yes
or
No
(This question must be answered.)
If Yes, date of work related injury/illness:_________________
Was your employer notified that your injury was caused by your job?
Yes
or
No
18. Identify the physician or hospital treating you for this disability: Name: ________________________________________________
Address: ____________________________________________________________ Telephone: (_____)_________________________
Employment Information – Beginning with your last employer, list all employment (both full and part-time) in the past 18
months. If you had more than 2 employers, list the remaining employers on the reverse side of this form in the space provided.
19a. Name and address of your most recent employer:
Period of employment: From _______________ To_____________
__________________________________________________
month/day/year
month/day/year
Work
__________________________________________________
Telephone: ____________________ Location _________________
(Street)
(City)
(State)
(Zip)
City
State
Occupation: ________________________________ Full time
Part time
Union _____________ Division___________________
Check the days of the week you normally work. SUN
MON
TUE
WED
THUR
FRI
SAT
19b. Name and address:
Period of employment: From _______________ To____________
__________________________________________________
month/day/year
month/day/year
Work
Telephone: ____________________ Location _________________
__________________________________________________
City
State
(Street)
(City)
(State)
(Zip)
Occupation: ________________________________ Full time
Part time
Union _____________Division___________________
Check the days of the week you normally work. SUN
MON
TUE
WED
THUR
FRI
SAT
20. Other Benefits – You Must Answer Each Question Listed Below For the Period of Disability Covered By This Claim:
a. Have you worked after your disability began? (Including self-employment)
Yes
No
b. Have you been receiving sick or vacation pay?
Yes
No
c. Have you been involved in a labor dispute?
Yes
No
21. Since your last day of work have you received, claimed or applied for: d. Any other disability benefits provided by your
a. Federal Social Security Disability Benefits?
Yes
No
employer or union?
Yes
No
b. Pension benefits from your most recent employer? Yes
No
e. Unemployment Insurance Benefits? Yes
No
c. Temporary Disability Benefits from another State? Yes
No
BE SURE TO COMPLETE AND SIGN PART A1
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