Fill and Sign the State of New Jersey Order Approving Case Nos Department Form

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC(DO) -370 Interactive(r. 4/24/13 ) ORDER APPROVING SETTLEMENT WITH DISMISSAL N.J.S.A. 34:15- 20 CASE NO’S .: VICINAGE : PETITIONER NAME: ATTORNEY FOR PETITIONER FEDERAL EMPLOYER NUMBER DATE OF BIRTH: MEDICARE ELIGIBLE: YES NO NAME: ADDRESS : ADDRESS: RESPONDENT vs TELEPHONE NUMBER (AREA CODE): NAME: APPEARING: ADDRESS : INSURANCE CARRIER NAME SELF -INSURED TPA ATTORNEY FOR RESPONDENT NAME: ADDRESS: ADDRESS : CLAIM NUMBER: TELEPHONE NUMBER (AREA CODE): APPEARING: This is a lump sum settlement between the p arties in the amount of $ pursuant to N.J.S.A. 34:15 -20 which has the effect of a dismissal with prejudice, being final as to all rights and benefits of the petitioner and is a complete and absolute surrende r and release of all rig hts arising out of this/these claim petitions(s). The payment hereunder shall be recognized as a payment of workers’ compensation benefits for insurance rating purposes only. The parties agree that this settlement [ does (complete page 2) / does not] contemplate a complete and absolute surrender and release of any and all rights by the petitioner’s dependents as defined by N.J.S.A. 34:15 -13 arising out of this/these claim petition(s). Order for Chil d Support Attached Addendum attached Further Agreed: ALLOWANCES REIMBURSE TAX IDENTIFICATION NUMBER TOTAL AMT. ALLOWED PAYABLE BY PETITIONER PAYABLE BY RESPONDENT MEDICAL FEE ALLOWED : (report an d/or testimony) ATTORNEY(S) FEE : STENOGRAPHIC SERVICE : MISCELLANEOUS FEES: Reason(s) for Section 20 (check all that apply): Contested issues regarding: JURISDICTION LIABILITY CAUSAL RELATIONSHIP DEPENDENCY WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY: After considering the circumstances, I find this settlement fair and just. PETITIONER’S ATTORNEY JUDGE OF COMPENSATION DATE PETITIONER (where applicable) JUDGE’S NAME THE ORIGINAL OF THIS DOCUMENT, SIGNED BY THE JUDGE OF COMPENSATION, WILL BE MAINTAINED ON FILE IN THE DIVISION OF WORKERS’ COMPENSATION, PURSUANT TO N.J.S.A. 34:15-121 et. seq. RESPONDENT’S ATTORNEY State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC(DO) -370 Interactive(r. 4/24/13 ) ORDER APPROVING SETTLEMENT WITH DISMISSAL N.J.S.A. 34:15- 20 Page 2 CASE NO’S .: VICINAGE : The parties agree that this settlement does contemplate a complete and absolute surrender and release of any and all rights b y the petitioner’s dependents as defined by N.J.S.A. 34:15-13 arising out of this/t hese claim petitioner(s). As the spouse or other person who may be defined as a dependent under N.J.S.A. 34:15-13 or the guardian or representative of such a person, I (we) consent to the entry of this order and recognize that this agreement is a complete and absolute surrender of any rights that I (we) may have pursuant to N.J.S.A. 34:15-13, should petitioner die as a result of the injuries, conditions, or exposures alleged in this/these claim petition(s). Na me Date Na me Date On Behalf of On Behalf of Na me Date Na me Date On Behalf of On Behalf of Na me Date Na me Date On Behalf of On Behalf of I certify that the above is (are) the only individual(s) who is (are) dependent(s) as defined in N.J.S.A. 34:15-13 at the present time. _________________________________________________________ Petitioner Da te WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY: After considering the circumstances, I find this settlement fair and just. PETITIONER’S ATTORNEY JUDGE OF COMPENSATION DATE PETITIONER (where applicable) JUDGE’S NAME THE ORIGINAL OF THIS DOCUMENT, SIGNED BY THE JUDGE OF COMPENSATION, WILL BE MAINTAINED ON FILE IN THE DIVISION OF WORKERS’ COMPENSATION, PURSUANT TO N.J.S.A. 34:15-121 et. seq. RESPONDENT’S ATTORNEY