Fill and Sign the Nj Workers Compensation 497319699 Form

                                                                                                  AM                                  PM                     New Jersey Reg. NOFederal Employer YES NO                                                           NO                    MADE       MADE                              EMPLOYEE       WITNESS             Form W C-2 (R-3-88) STATE OF NEW JERSEY INSURER'S INITIAL NOTICE OF ACCIDENT, AND INSURER'S AND SELF-INSURER'S STATEMENT OF WAGES AND AGREEMENT TO CARE FOR CASE FILE THIS FORM WITHIN TWENTY-ONE (21) DAYS AFTER THE HAPPENING OF ACCIDENT OR OBTAINING KNOWLEDGE OF OCCUPATIONAL DISEASE. MAIL ORIGINAL (WHITE) TO: RETAIN GREEN COPY DEPARTMENT OF LABOR Division of Workers' Compensation CN 381 Trenton, N.J. 08625-0381 DATE L & 1-1 PREPARED TYPE OR PRINT NAMEAND DISTRICT OFFICEADDRESS OF CARRIER ORSELF-INSURER. FOR INS. CO. USE ONLY THE NAMED EMPLOYER REPORTS AN INDUSTRIAL ACCIDENT OR OCCUPATIONAL DISEASEAS FOLLOWS. WHICH THIS CARRIER OR SELF-INSURER WILL PROCESS IN ACCORDANCE WITH APPLICABLE WORKERS' COMPENSATION LAWS 1. Employee (Full Name and Address) PLEASE PRINT OR TYPE 2 Occupation or Job Title 3. Age 4. Sex 5. Single 6. Social Security No 7. No. 8. Employer (Full Company Name and Address) Married Widowed Divorced DEPENDENTS 9. Date of Accident or Disease 10. Did Employee Die? Mo Day Yr. Time If "yes' Give Date and Mo Day Yr File Form WC-3A 11. Did Employee 12. If Already 13. If Not Able to Assume or Return to Work? Returned to Mo Day Yr. Work Give Probable Mo Day Yr. Work Give Date Date of Return identification No.-BASIS OF PAY 14 Output? Give average earnings 15. By Day? Give wages per day 16. By hour? Give Hourly Rate. 17 Were Board and Lodging 18. No. of hrs. in reg. furnished? work day Fill in 14 , or 15, or 16 $ $ $ 12. No. days in reg. work wk. 20. Amount of weekly wages $ DATE WC- I BY TITLE SIGNATURE OF PERSON PREPARING FORM DATE WC-2 BY TITLE SIGNATURE OF PERSON PREPARING FORM SIGNATURE OF EMPLOYEE (SEE REVERSE SIDE) MARK IF EMPLOYEE SIGNS WITH MARK. SAME MUST BE WITNESSED NOTE - IF NO COMPENSATION WAS OR IS TO BE PAID THE INJURED ORIF NATURE OF INJURY OR YOUR KNOWLEDGE OF ANY FACTSVARIES FROM THOSE REPORTED ON FORM WC-1, ''X'' THISBLOCK AND EXPLAIN ON REVERSE SIDE. The undersigned hereby affirms the correctness of the statements given andguarantees the paying of compensation, according to law. for temporary disabilityand for permanent injury, it any AUTHORIZED SIGNATURE W.C. DIVISION COPY See instructions on reverse side