Fill and Sign the Claim Process Waiting Period After Injuryminnesota Form

FINAL REPORT OF ACCIDENT WC-3 (R-9-94) THIS FORM MUST BE FILED AT THE CLOSE OF THE TEMPORARY DISABILITY PERIOD OR AS SOON THEREAFTER AS THE EXTENT OF THE PERMANENT INJURY CAN BE DETERMINED, WHICHEVER IS LATER. NEW JERSEY DIVISION OF WORKERS' COMPENSATION MAIL FORMS WC-3, WC-4, WC-5 TO CN 381 TRENTON, NEW JERSEY 08625-0381 Retain WC-6 for your records THE NAMED EMPLOYER REPORTS AN INDUSTRIAL ACCIDENT AS FOLLOWS WHICH THIS CARRIER OR SELF-INSURER WILL PROCESS IN ACCORDANCE WITH APPLICABLE WORKERS COMPENSATION LAWS. DATE WC-2 PREPARED SELF-INSURER OR CARRIER (GIVE DISTRICTOFFICE ADDRESS) 1. INJURED WORKER'S NAME AND HOME ADDRESS FOR INS. CO. USE ONLY 2. AGE 3. DATE OF ACCIDENT 3a. SOCIAL SECURITY NO. DIVISION USE ONLY Formal C.P. Filed S. DID INJURY CAUSE DEATH? IF -YES' IS CHECKED, THEN FORM WC-3A ON REVERSE SIDES MUST BE FILED ALSO. 4. PROBABLE DATE OF RECOVERY NO YES Informal Hearing 7. The undersigned hereby affirms the correctness of the 6. EMPLOYER AND EMPLOYER'S ADDRESS INCLUDING COUNTY Needed statements given and guarantees the paying ofcompensation, according to law for temporary disabilityand for permanent injury, If any. New Jersey Reg. No. x or Federal EmployerIdentification No. AUTHORIZED SIGNATURE 9. MEDICAL AID TO BE PAID 8. DID INJURY REQUIRE MEDICAL AID? 9a. COST OF MEDICAL AID RENDERED BY CARRIER OR EMPLOYER $ CARRIER EMPLOYER YES NO 12. BY HOUR? GIVE HOURLY RATE 11. BY DAY? GIVE WAGES PER DAY 10. OUTPUT EARNINGS? GIVE AVERAGE DAILY BASIS OF PAY FILL IN10 OR 11 OR 12 $ $ 13. NO. HOURS IN 16. WERE BOARD AND LODGING FURNISHED? 15. AMOUNT OF WEEKLY WAGES 14. NO. OF DAYS IN REG. WORK WEEK REG. WORKDAY LODGING BOARD DATE FORM WC-3 PREPARED ADDRESS 17. NAME OF PHYSICIAN 18. DETAILED X-RAY FINDINGS (IF SPACE INADEQUATE ATTACH X-RAY REPORT) 19. DETAILED DIAGNOSIS OF PHYSICIAN (GIVE DETAILS AS TO NATURE & EXTENT OF INJURIES (IF SPACE INADEQUATE ATTACH PHYSICIAN'S REPORT) 20. (a) GENERAL X-RAY FINDINGS (SEE REVERSE) 20. (b) TOTAL NO. OF TREATMENTS 20. (c) DATE OF DISCHARGE 21. GENERAL DIAGNOSIS (SEE REVERSE) 22. IS WORKER CAPABLE OF DOING SAME WORK AS YES BEFORE INJURY? NO 24. DATE PAYMENTS BEGAN 25. DATE INJURED RESUMED WORK 23. DATE DISABILITY BEGAN 28. IF YES DESCRIBE FULLY, GIVING PERCENTAGE OFMEMBER INVOLVED, IF UNDETERMINED (SEE REVERSE) 27. DID ANY PERMANENT INJURY RESULT FROM THIS ACCIDENT? 26. TOTAL TIME UNABLE TO WORK (SEE REVERSE) MONTHS WEEKS UNDETERMINED NO YES 30. NO. OF WEEKS AND AMOUNT PAID FOR TEMPORARY DISABILITY 29. AMOUNT OF WEEKLY COMPENSATION WEEKS $ $ 32. NO. WEEKS TO BE PAID FOR OTHER PERMANENT INJURY 33. TOTAL AMOUNT OF COMPENSATION 31. NO. WEEKS TO BE PAID FOR AMPUTATION FOR PERMANENT INJURY$ 34. IF THERE HAS BEEN AN INFORMAL (SEE REVERSE SIDE) SIGNATURE OF EMPLOYEE HEARING ON THIS CLAIM CHECK HERE MARK WITNESS SIGN HERE (IF EMPLOYEE SIGNS WITH MARK) IF SIGNED WITH MARK, SAME MUST BE WITNESSED W.C. DIVISION COPY $ $ 3 IF DEATH RESULTS, COMPLETE WC-3A IN ADDITION TO WC-3. IF DEATH RESULTS SUBSEQUENT TO FILING WC-3, AN AMENDED WC-3 MUST BE FILED AND WC-3A COMPLETED. WC-3A MUST BE FILED WITH THE DIVISION OF WORKERS' COMPENSATION WITHIN ONE MONTH AFTER THE DEATH OF THE INJURED. REPORT OF DEATH FORM WC-3A (8-4-93) Number Day Of Of Month Month Year (Name of Employer) Date of Accident Now Jersey Reg. No. (Name of Deceased Employee) or Federal Employer (Social Security No. of Deceased Employee) Identification No. (Name of Principal Dependent) 40. Give dale of preparing this blank (Street and Residence) 41. State the COST by you or your insurance carrier. $ 42. Name each dependent and date of birth, giving year, month and day. State relationship of each to deceased. (City or Town) 45. State the WEEKLY compensation to be paid the dependents at the various rates: Weeks Amount Rate $ $ 3A $ $ 43. Stale amount of compensation paid PRIOR to death $ $ 44. If any dependent Is physically or mentally deficient, specify which one. 46. State the TOTAL compensation paid and to be paid the dependents only 47. State the cost of BURIAL paid by The undersigned does hereby affirm the correctness of the foregoing statementsand agrees to accept compensation as herein set forth. you or your Insurance carrier (His Mark) The undersigned hereby affirms the correctness of the above statements, andagrees to pay to the dependents named, compensation as stated herein, in thesame manner and at the same periods that the deceased received his wages. (Signature of-Principal Dependent) it signed by mark, name must be witnessed (Signature of Employer or Insurance Carrier) (Signature of Witness, Parent or Guardian) Questions 20(a) & 21 a If the treating physician recommends, because of the adverse effect that knowledge of the answers may have on the employee, that the general x-ray findings or general medical diagnosis not be given to the employee, these questions may be answered by "see above". The answer "see above" constitutes your certification that the treating physician has made such a recommendation to you in writing. If the answer to question 27 is "undetermined'', insert the reason in the space following question 28 or attach an explanation to this form. Within a week after its expiration, if the 26 week wafting period (R. S. 34:15-16) is invoked, either an amended answer or form must be filed answering ''Yes'' or ''No'' to question 27, and completing question 28. Signature of Employee A reasonable effort must be made to have the employee sign this form. It shall suffice to ask the employee to come into the office for this purpose, and if the employee does not come into the office on the next working day or shift or refuses to sign, the words ''refused to sign'' may be inserted in lieu of the employee's signature. ''failed to appear" or $ $ $ $ Questions 27& 28a