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State of New Jersey Department of Labor and Workforce Development Division of Workers’ Compensation PO Box 381 Trenton, New Jersey 08625-0381 WC-366 ( r. 8/26/2015) DEPENDENCY CLAIM PETITION □ NEW FILING □ AMENDED FILING Case No.: ______________________________ Vicinage: ______________________________ **please enter above only if filing an Amended Claim** PETITIONER SOCIAL SECURITY NUMBER: □ SSN Not Available ATTORNEY FOR PETITIONER TAX IDENTIFICATION NUMBER: NAME: NAME: ADDRESS: ADDRESS: DATE OF BIRTH: SEX: TELEPHONE NUMBER: FAX NUMBER: □ A GUARDIAN OR OTHER REPRESENTATIVE IS FILING ON BEHALF OF THE PETITIONER. SEE SUPLEMENTAL PAGE FOR DETAILS. vs EMPLOYER NAME: INSURANCE CARRIER or SELF-INSURED ENTITY NAME: IF EMPLOYER IS KNOWN BY DIFFERENT NAME, PLEASE INDICATE HERE: ADDRESS: ADDRESS: CARRIER CLAIM NUMBER: INDICATE THE STATUS OF THE EMPLOYER: □ INSURED □UNINSURED □SELF-INSURED (PRIVATE) □SELF-INSURED (GOVT. AGENCY.) PERIOD OF COVERAGE: FROM: TO: □ See Supplemental Page for additional carriers □ INDIVIDUAL CORPORATE OFFICERS OR OTHERS ARE ALSO NAMED AS RESPONDENT(S). SEE SUPPLEMENTAL PAGE FOR DETAILS. DECEDENT SOCIAL SECURITY NUMBER: □ SSN Not Available DEPENDENTS (at time of death) NAME: (List Petitioner First) DATE OF BIRTH RELATIONSHIP NAME: 1. ADDRESS: 2. 3. 4. DATE OF BIRTH: SEX: □ See Attached For Additional Dependents TO THE DIVISION OF WORKERS’ COMPENSAT ION - INJURY AND EMPLOYMENT DETAILS: Date of Accident or Injury: Date of Death: Occupational Disease: □ YES □ NO If Occupational Disease Give Periods of Exposure: Where Injury Occurred (incl. town and county): How Injury Occurred: Nature of Injury: Cause of Death: Date Injury Reported: Injury Reported to Whom: Occupation and Type of Work: Gross Wages: $ Wage Period: Dependency Rate: $ Total Dependency Benefits Paid: $ Burial Expenses: $ Payable To: □ Demand is hereby made for answers to standard o ccupational disease interrogatories [N.J.A.C. 12:235-3.8(f)] □ Demand is hereby made for all records of medical treatment, examinations and diagnostic studies [N.J.A.C. 12:235-3.8 (c)] Was the decedent Medicare eligible or a Medicare beneficiary? □ YES □ NO Was the decedent eligible for Medicaid benefits at the time of the work injury? □ YES □ NO Did the decedent become eligible for Medicaid benefits after the work injury? □ YES □ NO What other facts are there that you believe important: Summary of Changes (Complete only if filing an Amended pleading ): Petitioner therefore requests that the Div ision of Workers’ Compensation determine the amount of compensation due Petitioner from said Respondent, pursuant to R.S. 34:15-7 et seq ., and that Petitioner may be awarded Petitioner’s costs in this proceeding, and suc h other or further relief as may be proper. ___________________________________________________ P etit io n er STATE OF NEW JERSEY COUNTY OF ________________________ Subscribed and sworn or affirmed to before me this _______ day of __________________ , 20_____ ____________________________________________ Please be advised that information collected from the filing of this claim petition may be used by the Division of Workers’ Compensation for record keeping, record access/distribution, and case scheduling purposes. Petitions filed with the Division are public documents and may be inspected and copied exc ept where prohibited by Section 34:15-128 of the Workers’ Compensation Statute. The Privacy Act, 5 U.S.C. §552a, the Social Security Act, 42 U. S.C. § 405, and N.J.S.A. 34:15-1 et seq. authorize the Division of Workers’ Compensation to request that the Pe titioner supply the Division with his or her Social Security Number for record keep ing purposes and cross-matches with the Social Security Administra tion, Workforce New Jersey, Temporary Disability Insurance and an y other proper public purpose. Page 2 State of New Jersey Department of Labor and Workforce Development Division of Workers’ Compensation PO Box 381 Trenton, New Jersey 08625-0381 DCPsupp 8/26/2015 DEPENDENCY CLAIM PETITION SUPPLEMENTAL PAGE Case No.: ______________________________ Vicinage: ______________________________ GUARDIAN OR REPRESENTATIVE NAME: ADDRESS: RELATIONSHIP TO PETITIONER: ADDITIONAL CARRIERS NAME: ADDRESS: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: TO: NAME: ADDRESS: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: TO: NAME: ADDRESS: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: TO: NAME: ADDRESS: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: TO: INDIVIDUAL CORPORATE OFFICERS/PARTNERS/LLC MEMBERS NAME: ADDRESS: NAME: ADDRESS: NAME: ADDRESS: NAME: ADDRESS: