Fill and Sign the Informal Hearing Workers

YES YES NO NO      Employee       Phone No.       Birth Date       Address             Zip Code       County       Employer       Address             Zip Code       County       Insurance Company       Date of Accident       Address             Zip Code       Type of Injury       Hearing Requested by       REGISTRATION NUMBER       IDENTIFICATION NUMBER             APPLICATION FOR INFORMAL HEARING COMPLETE AND RETURN TO NEW JERSEY DEPARTMENT OF LABOR DIVISION OF WORKERS' COMPENSATION PO BOX 381 TRENTON, NEW JERSEY 08625-0381 PLEASE PRINT Social Security No.OR TYPE (Must be 9 Digits) City Cit y Cit y 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 SELF-ADDRESSED STAMPED ENVELOPE) COMPLETE ONE: NEW JERSEY EMPLOYER OR FEDERAL EMPLOYER WERE YOU ELIGIBLE FOR MEDICAID BENEFITS AT THE TIME OF THE ACCIDENT? DID YOU BECOME ELIGIBLE FOR MEDICAID BENEFITS AFTER THE ACCIDENT? YOU ARE ADVISED THAT MEDICAID PAYMENTS RELATED TO THE ACCIDENT ARE TO BE REPAID IN ACCORDANCE WITH N.J.S.A. 30:40-1, 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 medical 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. WC(CF)-66 (R-8-98)