Fill and Sign the Nj Discrimination Form

I feel that I was discriminated against because of my filing or attempting to file a workers' compensation claim.. I feel that I was discriminated against because of my testimony or plans to testify in a workers' compensation proceeding. No Yes Claim #, No Yes. Claim Petition #                                                                                                                                                         $                   Yes No Department of Labor COMPLAINT OF Office of Special Compensation Funds P 0 Box 399 Trenton, New Jersey 08625-0399 DISCRIMINATION N.J.S A. 34:15-39.1 et seq. The New Jersey Workers' Compensation Law (NJSA 34:15-1 et seq.) provides that it shall be unlawful for an employer to discharge or otherwise discriminate against an employee because that employee has filed or has attempted to file a claim for workers' compensation benefits or has testifiedor has planned to testify in any proceeding before the Division of Workers' Compensation. This complaint is to be completed by an employee who alleges such discrimination. 01. Your Name 02. Your Social Security Number: (Last) (First) (Middle) 03. Your complete home address (Street Number- No PO Boxes) (City) (County) (State) (Zip Code) 04. Your Home Telephone Number 05. If Employed, your Daytime Telephone N umber: 06. Nature of Complaint (Check One): a. b. 07. Name of Employer 08. New Jersey Employer Identification Number (if known): 09. Complete Employer Address (Street Number- No PO Boxes) (City) (County) (State) (Zip Code) 10. Employer Agent Name: 11. Employer Agent Telephone: COMPLETE ITEMS 12 THROUGH #20 ONLY IF IOU HAVE CHECKED BOX ''a" IN ITEM #06, ABOVE 12. Name of Employer's Workers' Compensation Insurance Carrier 13. Have you filed a claim with this carrier 14. Have you filed a Claim with the NJ Div. of Workers' Compensation'? 15.. Date of Accident/Illness 16. Your Occupation at Time of Accident/Illness: 17. Nature of Your Disability 18. Your Gross Weekly Wages at Time of Accident/Illness Per Week 19. Your Job Duties at Time of Accident/Illness 20, Are You Currently Able to Perform These Duties? (C heck One) (CONTINUED ON BACK) SCF-4 (R 7-98) No Yes (If Yes, complete item #24) No Yes ( If Yes, complete item #26)                                                             S             State of New Jersey, County of                   Subscribed and sworn before me this             (CONTINUED FROM FRONT) COMPLETE ITEMS # 21 THROUGH #26 ONLY IF YOU HAVE CHECKED BOX ''b'' IN ITEM #6 21. Full Name of Petitioner in Workers' Compensation Case: 22. Claim Petition Number: 23. Did You Testify in this Case? (Check One) 24, Date and Location of Testimony: 25. Are You Scheduled to Testify in this Case? (Check Chic,) 26. Scheduled Date and Location of Testimony 27. Date of Termination or Other Personnel Action: 29. If Currently Employed, Employer's Name and Address 28. Reason Give by Employer for Action: 30. If Employed, Your Current Weekly Gross Wages: Per Week 31. State here and/or on attached sheets, the reason(s) for your alleging discrimination: , of full age, being duly sworn according to law, on his/her oath deposes and says: That he/she is the complainant named in the foregoing complaint; that he/she has read the same; and that the matters and thing therein set forth are true accord in g to the best of his/her knowledge and belief. (Complainant Signature) day of