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SOCIAL SECURITY NUMBER

Claimant’s Name: _______________________________Clt’s Tele #(____)______________

Clt’s Address:__________________________________________________________________

PART C

TO BE COMPLETED BY YOUR EMPLOYER OR COMPANY REPRESENTATIVE

WDS-1(R-1-07)

2. EMPLOYER STATUS

8. BASE WEEKS AND BASE YEAR GROSS

What is your Federal Employer Identification Number: ___________________

WAGES A BASE WEEK is a calendar week in

which the claimant had New Jersey earnings of $143

3. PRIVATE PLAN COVERAGE

(NJ approved plan/replaces State Plan coverage)

or more during the Base Year. The BASE YEAR is

a. Do you have a New Jersey approved Private Plan?

Yes

the 52 calendar weeks preceding the week in which

b. If “Yes”, is claimant covered under this approved Private Plan?

Yes

the disability occurred.

4. LAST ACTUAL DAY WORKED before this disability

(do not use payroll week ending dates)

______|______|______

a. Total Number of Base Weeks _______________

(Month

/ Day / Year)

a. Exact reason for separation from work

(include labor dispute)

_______________________________

b. Total Gross Wages in Base Year ____________

b. Is lack of work:

temporary?

permanent?

Include all wages earned by the claimant

c. Has claimant returned to work?

Yes

__________________________________________

If “Yes”, give date

_______|_____|______

(Month / Day

/ Year)

9. REGULAR WEEKLY WAGE $_____________

d. If the work was intermittent, list dates:_______________________________

5. CONTINUED PAY (do not enter wages earned prior to disability)

10. Weekly wages

a. Have you paid or expect to pay the claimant for any period after the last day

Indicate below: dates and claimant’s GROSS

of work?

Yes

earnings in N.J. employment during the listed

b. If “yes” give dates:

FROM ______|_____|_____ TO _____|_____|_____

calendar weeks.

Month / Day / Year)

(Month / Day / Year)

Description of

Calendar

Gross

c. Amount per week $______________, if amount varies attach list of dates

Calendar Week

Week

Wages

and amounts.

Ending Date

d. Check the number that best describes the monies paid in item c.

Week Disability

1. Regular weekly wages and/or sick pay

Began

2. Regular vacation (if designated for a specific time period)

Week Before

3. Pension

Disability

4. Difference between regular weekly wage and disability benefits to be

2nd Week Before

received

Disability

5. Full salary advanced to effect #4 above

3rd Week Before

6. Supplemental benefits or gratuities

Disability

Note: Items 1, 2, and 3 may reduce benefits to the claimant

4th Week Before

6. GOVERNMENT EMPLOYEES (Complete this section)

Disability

a. Payroll number (For N.J. State Employees) ________________________

5th Week Before

b. Number of earned sick leave days as of the last day worked. ___________

Disability

c. Has the claimant filed for or received Employment Disability Leave

6th Week Before

(SLI)?

Yes

Disability

d. If claimant has applied for or received donated leave, attach dates and

7th Week Before

amounts on a separate sheet of paper.

Disability

7. WORKERS’ COMPENSATION LIABILITY

8th Week Before

a. Did the claimant’s disability happen in connection with his/her work or

Disability

while on your premises, or was the disability due in any way to his/her

9th Week Before

occupation?

Yes

Disability

b. If “Yes”, have you filed or do you intend to file a Workers’ Compensation

claim on behalf of this claimant?

Yes

10th Week Before

c. If “Yes,” list Workers’ Compensation insurance carrier below:

Disability

Name______________________________Telephone (

) _______________

TOTAL GROSS WAGES FOR

Address__________________________________________________________

ABOVE WEEKS

Policy #_______________________ Claim #___________________________

Are you exempt from FICA tax?

Yes

11. Check the days of the week the employee normally works. SUN

MON

TUE

WED

THUR

FRI

SAT

Firm Name __________________________________________I CERTIFY THE INFORMATION GIVEN ABOVE IS CORRECT

Address ____________________________________________ Signed_____________________________Date___________________

City, State, Zip_______________________________________ Print or Type Name _________________________________________

Mailing Address, If Different____________________________ Official Title_______________________________________________

FAX No. (

) _______________________ Telephone (

) _____________________E-Mail Address_______________________

Form Ds-1 - Claim For Disability Benefits - New Jersey Department Of Labor And Workforce Development Page 6

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