New Jersey Administrative Code
Title 12 - LABOR AND WORKFORCE DEVELOPMENT
Chapter 235 - RULES OF THE DIVISION OF WORKERS' COMPENSATION
Subchapter 7 - UNINSURED EMPLOYER'S FUND
Section 12:235-7.3 - Certification
Universal Citation: NJ Admin Code 12:235-7.3
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Petitioner shall submit a certification when filing a motion for an uninsured claim. The certification shall be specific, and shall contain the following information if known or available to the petitioner and should be supplemented as such information becomes known or available to the petitioner:
1.
The date of hire immediately preceding the date of the accident, injury or
occupational exposure;
2. The length of
employment: If not continuous, list all dates of employment;
3. Copies of petitioner's W-2 forms for all dates
of employment during the year in which the accident occurred;
4. Pay stubs for or other documentation in support
of all wages received from respondent for the six months immediately preceding the
date of the accident or occupational exposure;
5. The total wagers received from respondent for
12 months immediately preceding the accident, which includes salary, gratuities,
services, in lieu of wages, meals or lodging;
6. The name, address (business and personal) and
phone number of the respondent and any corporate officer or manager of the
company;
7. Any documents relating to
the employer/employee relationship or lack thereof;
8. A statement of facts which establish the
employer-employee relationship;
9. The
name, address and phone number of all persons with knowledge of the existence of an
employer/employee relationship between petitioner and respondent;
10. The address and/or other identifying
information about where the injury occurred, including the name of the owner of the
property and the reason why the employee was at the location where the injury
occurred;
11. The name, address and
phone number of all witnesses to the accident, and whereabouts of respondent when
the accident occurred;
12. The name,
address and phone number of all persons with any knowledge of the
accident;
13. The date on which a
medical provider was first contacted concerning injuries sustained in the accident
or occupational condition;
14. The name
and address of all treating physicians and the name and address of any hospital,
laboratory or other facility where treatment was received;
15. Copies of all medical reports from the
hospitals and treating physicians;
16.
Medical insurance coverage for employee and/or spouse, and if available, the name
and address of the company and the policy number;
17. A detailed listing of medical expenses which
have been paid, the dates the medical services were provided, the names of
individuals and entities providing such services, and the sources and amounts of
such payments; and
18. Whether or not
the petitioner is receiving or has applied for Social Security, unemployment
compensation, temporary disability insurance, disability insurance, pensions or any
other wage-related benefits.
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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