Second Injury Fund Verified Petition

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C.P. NO’S.:

State of New Jersey

SECOND INJURY FUND

Department of Labor & Workforce Development

VERIFIED PETITION

DIVISION OF WORKERS’ COMPENSATION

VICINAGE:

Office of Special Compensation Funds

SCF-161 (R 12-07)

SSN Unavailable

SOCIAL SECURITY NUMBER:

FEDERAL EMPLOYER IDENTIFATION NUMBER:

NAME:

ADDRESS:

TELEPHONE NO:

NAME:

NAME :

Indicate if

Self- Insured or

Uninsured

ADDRESS:

TO THE COMMISSIONER OF LABOR AND WORKFORCE DEVELOPMENT OF THE STATE OF NEW JERSEY:

Petitioner hereby alleges eligibility for benefits from the Second Injury Fund pursuant to N.J.S.A. 34:15-95 et seq., and respectfully states

the following:

Number of Dependents:

Date of Birth:

Age:

Sex:

Marital Status:

(If one or more, see Page 3)

Educational Background:

Special Skills:

Employment History: (List all former employers, dates of employment and job descriptions; use additional sheets as required.

Pre-Existing Medical Conditions: (List physical and/or psychiatric conditions which pre-existed your last compensable accident of exposure or dates of onset)

Description and Date of Last Compensable Accident or Occupational Disease Exposure:

Gross Weekly Wages for Last Compensable Injury:

Weekly Benefit Rate for Last Compensable Injury:

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