Fill and Sign the New Jersey Workers Compensation 497319701 Form

YES NO YES NO YES NO YES NO UNDETERMINED                                                                        Formal       Informal                   New Jersey       Federal       CARRIER                                            LODGING                                                                                                                                       WC-4 (R-9-94) FINAL REPORT OF ACCIDENT STATE OF NEW JERSEY DEPARTMENT OF LABOR DIVISION OF WORKERS' COMPENSATION CN 381 - TRENTON, N. J. 08625-0381 THE NAMED EMPLOYER REPORTS AN INDUSTRIAL ACCIDENT AS FOLLOWS WHICH THIS CARRIER OR SELF-INSURER WILL PROCESS INACCORDANCE WITH APPLICABLE WORKERS COMPENSATION LAWS. DATE WC-2 PREPARED1. INJURED WORKER'S NAME AND HOME ADDRESS SELF-INSURER OR CARRIER (GIVE DISTRICT OFFICE ADDRESS) FOR INS. CO. USE ONLY 2. AGE 3. DATE OF ACCIDENT 3a. SOCIAL SECURITY NO. DIVISION USE ONLY 4. PROBABLE DATE OF RECOVERY S. DID INJURY CAUSE DEATH? IF -YES' IS CHECKED, THEN FORM WC-3A ONREVERSE SIDES MUST BE FILED ALSO. 6. EMPLOYER AND EMPLOYER'S ADDRESS INCLUDING COUNTY 7. The undersigned hereby affirms the correctness of the Needed statements given and guarantees the paying ofcompensation, according to law for temporary disabilityand for permanent injury, If any. or x Identification No. AUTHORIZED SIGNATURE 8. DID INJURY REQUIRE MEDICAL AID? 9. MEDICAL AID TO BE PAID 9a. COST OF MEDICAL AID RENDERED BY CARRIER OR EMPLOYER $ BASIS OF PAY FILL IN10 OR 11 OR 12 10. OUTPUT EARNINGS? GIVE AVERAGE DAILY 11. BY DAY? GIVE WAGES PER DAY 12. BY HOUR? GIVE HOURLY RATE $ $ $ 13. NO. HOURS IN 14. NO. OF DAYS IN REG. WORK WEEK 15. AMOUNT OF WEEKLY WAGES 16. WERE BOARD AND LODGING FURNISHED? REG. WORKDAY $ 17. NAME OF PHYSICIAN ADDRESS DATE FORM WC-3 PREPARED 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 BEFORE INJURY? 23. DATE DISABILITY BEGAN 24. DATE PAYMENTS BEGAN 25. DATE INJURED RESUMED WORK 26. TOTAL TIME UNABLE TO WORK 27. DID ANY PERMANENT INJURY RESULT FROM THIS ACCIDENT? WEEKS MONTHS (SEE REVERSE) 28. IF YES DESCRIBE FULLY, GIVING PERCENTAGE OFMEMBER INVOLVED, IF UNDETERMINED (SEE REVERSE) 29. AMOUNT OF WEEKLY COMPENSATION 30. NO. OF WEEKS AND AMOUNT PAID FOR TEMPORARY DISABILITY $ WEEKS $ 31. NO. WEEKS TO BE PAID FOR AMPUTATION 32. NO. WEEKS TO BE PAID FOR OTHER PERMANENT INJURY 33. TOTAL AMOUNT OF COMPENSATION FOR PERMANENT INJURY $ 34. IF THERE HAS BEEN AN INFORMAL HEARING ON THIS CLAIM (SEE REVERSE SIDE) SIGNATURE OF EMPLOYEE 4 CHECK HERE MARK WITNESS SIGN HERE (IF EMPLOYEE SIGNS WITH MARK) IF SIGNED WITH MARK, SAME MUST BE WITNESSED W.C. DIVISION COPY            Now Jersey Reg. No.       Federal Employer             40. Give dale of preparing this blank       41. State the COST by you or your insurance carrier. $                                                                                                       $                   PRIOR to death       $                         46. State the TOTAL compensation paid       47. State the cost of BURIAL paid by       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. FORM WC-3A (8-4-93) REPORT OF DEATH Number DayO fOf Month Month Year (Name of Employer) Date of Accident or (Name of Deceased Employee) (Social Security No. of Deceased Employee) Identification No. (Name of Principal Dependent) (Street and Residence) 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: Rate Weeks Amount $ $ $ $ $ $ 43. Stale amount of compensation paid $ $ 3A 44. If any dependent Is physically or mentally deficient, specify which one. and to be paid the dependents only 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) (Signature of-Principal Dependent) it signed by mark, name must be witnessed 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 Witness, Parent or Guardian) (Signature of Employer or Insurance Carrier) 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. Questions 27& 28 a 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 ''failed to appear" or 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.