Fill and Sign the New Jersey Social Security Form

Worker's Name      2. Social Security Number       Employer's Name and Address             Injury Date             No (if ''no', go to #9) Other (If ''other", go to #9) Denied Allowed (if "pending" or "denied" go 80% Average Current Earnings (ACE)       Enter the amount of the worker entitlement       No (if "no', go to #9) #1       #4                                           WC- 124 (6-86) New Jersey Department of LaborD iv is i on of Workers' Compensatio n REQUEST FOR SOCIAL SECURITY INFORMATION Part I TO BE COMPLETED BY WORKERS' COMPENSATION (WC) or INSURANCE COMPANY REPRESENTATIVE or WORKER'S ATTORNEY*. 1 .3 . 4. 5. information needed from SSA (check a or b) a. 80% ACE only b. 80% ACE plus Social Security Benefits 6. Signature of WC, or Insurance Company, Representative or Worker's Attorney Dat e *NOTE: REQUESTS FROM A WORKER'S ATTORNEY MUST BE ACCOMPANIED BY A SIGNED AUTHORIZATION ALLOWING INFORMATION TO BE SENT TO THE ATTORNEY. Part II TO BE COMPLETED BY SSA 1, Has the above named worker applied for social security benefits? Yes 2. If ''yes", what is the type of benefit? Disability 3. What is the status of the disability claim? Pending to #9) 4. 5. 6. Are there any auxiliary beneficiaries? Yes 7. Enter the amount which auxiliary was awarded as of the date of entitlement: Auxiliary #2 #3 #5 #6 8. 9. Use the reverse to show the date of new entitlements or terminations of an auxiliary. Signature and Title of SSA Representative Date ADDRESS REQUESTS TO: Social Security Administration 26 Federal Plaza, Room 40-114 New York, New York 10278 ATT: Disability Inquiries Sec. RETURN INFORMATION TO: