New Jersey Administrative Code
Title 12 - LABOR AND WORKFORCE DEVELOPMENT
Chapter 235 - RULES OF THE DIVISION OF WORKERS' COMPENSATION
Subchapter 5 - SECOND INJURY FUND CASES
Section 12:235-5.3 - Filing
Universal Citation: NJ Admin Code 12:235-5.3
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The verified petition for benefits shall be filed in accordance with 34:15-95.1 and shall include a succinct and accurate description of all medical, legal and factual basis upon which the petitioner alleges eligibility for Fund benefits pursuant to 34:15-95. The verified petition shall be under oath or affirmation and be accompanied by all physician's reports in possession of the applicant or the applicant's attorney.
(b) The verified petition shall also include the following:
1. Name and address of
petitioner;
2. Social security number of
petitioner;
3. Age and date of birth of
petitioner;
4. Marital status and
educational background of petitioner;
5.
A summary of petitioner's employment history;
6. A description of disabilities which existed
prior to the date of the last compensable injury, and the date of onset of
each;
7. The last compensable injury,
indicating the date and a description of the occurrence; a description of the
injury; brief description of the medical treatment for the injury; a description of
permanent injury; name and address of employer and its insurance carrier;
petitioner's wages and compensation rate; and a listing of all compensation paid to
date for this injury;
8. An indication
as to whether a third party tort claim has been made as to the last compensable
injury, stating the name and address of the third party and the status of the
claim;
9. A copy of all reports which
are in the possession or control of the party filing the applications from all
proposed expert witnesses and all treating physicians;
10. A description of all wage replacements
presently being received by the petitioner;
11. References to all prior allowances and awards
in workers' compensation matters concerning the petitioner, including the date of
the accident and the extent of the allowance or award.
(c) Respondent shall provide all evaluative reports to the Second Injury Fund at the first motion hearing.
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