Fill and Sign the Department of Labor and Workforce Developmentcontact Us Form

NEW AMENDED Name of the Insurance Company can be obtained either from the Employer or by writing to the Compensation Rating and Inspection Bureau 60 Park Place, Newark, New Jersey 07102 (BE SURE TO INCLUDE A SELF -ADDRESSED STAMPED ENVELOPE) Date of Accident Type of Injury Hearing Requested by: EMPLOYEE (PETITIONER) EMPLOYER INSURANCE CARRIER PETITIONERS ATTORNEY: If checked, please provide Name and Address of Attorney: NAME: ADDRESS: TELEPHONE NUMBER: WERE YOU ELIGIBLE FOR MEDICAID BENEFITS AT THE TIME OF THE ACCIDENT? YES NO DID YOU BECOME ELIGIBLE FOR MEDICAID BENEFITS AFTER THE ACCIDENT? YES NO YOU ARE ADVISED THAT MEDICAID PAYMENTS RELATED TO THE ACCIDENT ARE TO BE PAID IN ACC ORDANCE WITH N.J.S.A. 30:14 -1, et. seq. IMPORTANT: This proceeding will not prevent the Statute of Limitations from expiring. FAILURE TO FILE A FORMAL PETITION within two years of the date of accident or the last payment and / or authorized med ical treatment by the employer’s insurance carrier can bar any action on a claim filed after that time. TO INSURE IMMEDIATE PROCESSING, PLEASE COMPLETE THIS FORM IN FULL OR IT WILL BE RETURNED Signature Date The Privacy Act, 5 U.S.C. § 552a, the Social Security Act, 42 U.S.C. § 405, and N.J.S.A. 34:15- 1 et. seq . authorize the Division of Workers’ Compensation to request that the Petitioner supply the Division with his or her Social Security number for record keeping purposes and cross -matches with the Social Security Administration, Workforce New Jersey, Temporary Disability Insurance and any other proper public purpose. State of New Jersey Department of Labor and Workforce Development Division of Workers’ Compensation PO Box 381 Trenton, NJ 08625 -0381 WC(CF) -66 (R -2-06) APPLICATION FOR INFORMAL HEARING FOR STAFF U SE ONLY CASE NO: ________________________ VICINAGE: _______________________ ORIGINAL INFORMAL CASE # SOCIAL SECURITY NUMBER EMPLOYEE ADDRESS (Including County) TELE PHONE NUMBER DATE OF BIRTH EMPLOYER ADDRESS (Including County ) INSURANCE CARRIER ADDRESS