Second Injury Fund Verified Petition Page 3

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Prior Compensation Awards: (Please list all claim petition numbers, dates of injury or last exposure, percentages of disability and body parts and attach any copies of Judgments

in your possession:

Are you currently employed or engaged in a business activity?

Yes If Yes, please provide the following information:

Name, Address and Telephone of Employer:

Job Title and Nature of the duties performed:

Number of hours worked per week:

Gross Weekly Wage or Earnings:

I believe that I am totally and permanently disabled as the result of a combination of my pre-existing physical and/or

psychiatric conditions and my last compensable injury or disease. Further, I believe that the exclusionary provisions of

N.J.S.A. 34:15-95 do not apply to my case. Accordingly, I hereby petition for Second Injury Fund benefits under the

provisions of N.J.S.A. 34:15-95, et seq. Therefore I hereby, on my oath, affirm that I have read the foregoing and am familiar

with the contents thereof and that the matters set forth are true to the best of my knowledge and belief.