Fill and Sign the New Jersey Compensation Form

Yes No Yes No Yes No                                                                                                                        Is Correct Has Been Corrected                                                                                                                                           DECEDENT WC-171 (10-93) State of New Jersey RESPONDENTS ANSWER TO DEPENDENCY CLAIM PETITION C.P. NO Department of Labor DIVISION OF WORKERS' COMPENSATION DOP E T I T I O N E R FEDERAL EMPLOYER'S IDENTIFICATION NUMBER:(If none, insert Social Security No.) NAME: NAME: ADDRESS: COUNTY OF RESIDENCE:ADDRESS: A T T P O R N E Y F O R R E S P O N D E N T TELEPHONE (Area Code) R E S P O N D E N T NAME VS NAME: (Indicate If Not Covered or Self-Insured) COUNTY OF RESIDENCE: ADDRESS: ADDRESS: C A R RI E R CLAIM FILE NO.:IN S U R A N C E IN ANSWER TO THE DEPENDENCY CLAIM PETITION FILED IN THIS CAUSE RESPONDENT STATES: RESPONDENT AND CARRIER INFORMATION SUPPLIED BY PETITIONER SOCIAL SECURITY NUMBER: ADDRESS: NAME: DATE INJURY DATE EMPLOYER DATE INJURY DATE STOPPED DATE RETURNED TO DATE OF DEATH OCCURRED HAD KNOWLEDGE OF INJURY REPORTED WORK WORK OCCUPATION AND TYPE OF WORK HOW INJURY OCCURRED WHERE NATURE OF INJURY CAUSE OF DEATH MEDICAL EXPENSES BURIAL EXPENSES PAID BY RESPONDENT Yes No $ $ GROSS WEEKLY WAGE RATE OF COMPENSATION COMPENSATION RECEIVED FOR TOTAL COMPENSATION FROM EMPLOYER INJURY $ $ PER $ $ EMPLOYER FURNISHED MEDICAL AID DECEDENT GAVE WRITTEN NOTICE OFARTICLE 2 EXEMPTION DECEDENT RECEIVED WRITTEN NOTICE OFARTICLE 2 EXEMPTION Respondent agrees with information concerning Dependents named in the Dependency Claim PetitionIf no, explain. Yes No Respondent submits the following additional information (Enter none, if appropriate. Use additional Sheets, if required). (Over)                                                                      ( )- IMPORTANT :In implementing R.S. 34:15-102 of the Workers' Compensation Law, the Division has stated that Respondent's Answer to Dependency Claim Petition shall be filed with the Division within ten days of service upon the Respondent unless further time is granted by the Division.'' Under the Law (R.S. 34:15- 53) the Division may assign the case to a hearing office if the Respondent's Answer is not filed within the stipulated time allowed. STATE OF NEW JERSEY COUNTY OF :ss. of full age, being duly sworn, according to law deposes and says that: Deponent is the Respondent named in the foregoing Answer to Claim Petition; deponent has read the same; is familiar with the contents thereof; and the matters and things therein set forth are true according to the best of deponent's knowledge and belief. Subscribed and sworn to before me this day of (Respondent) (The foregoing affidavit may be sworn to before any person authorized to administer an oath. In lieu of an affidavit, an attorney licensed to practice law in this State may complete the certification below). I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are wilfully false, I am subject to punishment. Dated: ATTORNEY FOR RESPONDENT ADDRESS Telephone No. Area Code