Fill and Sign the Carrier Attorneyinsurertpaself Insured Employer Forms

Form WC-2 (R-3-88) STATE OF NEW JERSEY INSURER'S INITIAL NOTICE OF ACCIDENT, AND INSURER'S AND SELF-INSURER'S STATEMENT OF WAGES AND AGREEMENT TO CARE FOR CASE FILE THIS FORM WITHIN TWENTY-ONE (21) DAYS AFTER THE HAPPENING OF ACCIDENT OR OBTAINING KNOWLEDGE OF OCCUPATIONAL DISEASE. MAIL ORIGINAL (WHITE) TO: RETAIN GREEN COPY DATE L & 1-1 PREPARED DEPARTMENT OF LABOR Division of Workers' Compensation CN 381 Trenton, N.J. 08625-0381 TYPE OR PRINT NAME AND DISTRICT OFFICE ADDRESS OF CARRIER ORSELF-INSURER. FOR INS. CO. USE ONLY THE NAMED EMPLOYER REPORTS AN INDUSTRIAL ACCIDENT OR OCCUPATIONAL DISEASE AS FOLLOWS. WHICH THIS CARRIER OR SELF-INSURER WILL PROCESS IN ACCORDANCE WITH APPLICABLE WORKERS' COMPENSATION LAWS 1. Employee (Full Name and Address) PLEASE PRINT OR TYPE 2 Occupation or Job Title 4. Sex 3. Age 7. No. 6. Social Security No 5. Single DEPENDENTS 8. Employer (Full Company Name and Address) 10. Did Employee Die? 9. Date of Accident or Disease If "yes' Give Date and Mo Mo Yr AM Time Yr. Day Day File Form WC-3A PM New Jersey Reg. NO 12. If Already 13. If Not Able to Assume 11. Did Employee or Return to Work? Work Give Probable Returned to Federal Employer Date of Return Work Give Date YES NO identification No.- 17 Were Board and Lodging 16. By hour? Give Hourly Rate. BASIS OF PAY 15. By Day? Give wages per day 14 Output? Give average earnings 18. No. of hrs. in reg. furnished? work day $ NO YES Fill in 14, or 15, or 16 12. No. days in reg. work wk. 20. Amount of weekly wages BY MADE DATE WC- I TITLE SIGNATURE OF PERSON PREPARING FORM BY MADE DATE WC-2 TITLE WITNESS EMPLOYEE IF EMPLOYEE SIGNS WITH MARK. SAME MUST BE WITNESSED MARK SIGNATURE OF EMPLOYEE (SEE REVERSE SIDE) NOTE - The undersigned hereby affirms the correctness of the statements given andguarantees the paying of compensation, according to law. for temporary disabilityand for permanent injury, it any IF NO COMPENSATION WAS OR IS TO BE PAID THE INJURED ORIF NATURE OF INJURY OR YOUR KNOWLEDGE OF ANY FACTSVARIES FROM THOSE REPORTED ON FORM WC-1, ''X'' THISBLOCK AND EXPLAIN ON REVERSE SIDE. AUTHORIZED SIGNATURE See instructions on reverse side W.C. DIVISION COPY $ $ $ Married Widowed Divorced SIGNATURE OF PERSON PREPARING FORM Mo Yr. Day Mo Yr. Day