Fill and Sign the Trenton New Jersey 08625 0381 Form

State of New Jersey Department of Labor and Workforce Development Division of Workers’ Compensation PO Box 381 Trenton, New Jersey 08625-0381 WC-368 r.8/26/2015 APPLICATION FOR REVIEW OR MODIFICATION OF FORMAL AWARD □ ORIGINAL □ AMENDED FILING Case No.: ______________________________ Vicinage: ______________________________ **Case Number Required** PETITIONER SOCIAL SECURITY NUMBER: 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 additional page for details. vs RESPONDENT NAME: INSURANCE CARRIER / TPA NAME: ADDRESS: ADDRESS: CARRIER CLAIM NUMBER: □ If uninsured, individual corporate offi cers, or others, are also named as respondent(s). S ee Supplemental Page for details. □ See Supplemental Page for additional carriers TO THE DIVISION OF WORKERS’ COMPENSATION: _______________________________________________ ( Name of Petitioner or Respondent), pursuant to N.J.S.A. 34:15-27 seeks modification and review of the award entered on ____________________________, for the follo wing reasons: □ See Attached For Additional Information As to Claim Petitioner: Date of Injury: Date of Last Comp. Pd: Present Employment Status: Claim Petitions filed since last award: This is the ____________ Application for Review or Modification of this award. (Number) □ Demand is hereby made for all records of medical treatmen t, examinations and diagnostic studies. [N.J.A.C. 12:235-3.8 (c)] ARE YOU MEDICARE ELIGIBLE OR A MEDICARE BENEFICIARY? □ YES □ NO WERE YOU ELIGIBLE FOR MEDICAID BENEFITS AT THE TIME OF THE WORK INJURY? □ YES □ NO DID YOU BECOME ELIGIBLE FOR MEDICAID BENEFITS AFTER THE WORK INJURY? □ YES □ NO Summary of Changes (Complete only if filing an Amended pleading ): STATE OF NEW JERSEY, COUNTY OF ________________________ Subscribed and sworn or affirmed to before me this _______ day of __________________ , __________ ____________________________________________ _____________________________________________________ Applicant Please be advised that information collected from the filing of th is Application for Review or Modification of Formal Award may be used by the Division of Workers’ Compensation for reco rd keeping, record access/distribution, and case scheduling purposes. Petitions filed with the Division are public documents and may be inspected and copied except 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 Applicant s upply the Division with his or her Social Security Number for record keeping purpos es and cross-matches with the Social Security Administration, Work force New Jersey, Temporary Disability Insu rance and any other proper public purpose. DIVISION OF WORKERS’ COMPENSATION State of New Jersey Department of Labor and Workforce Development Division of Workers’ Compensation PO Box 381 Trenton, New Jersey 08625-0381 WC-368supp r. 8/26/2015 APPLICATION FOR REVIEW OR MODIFICATION OF FORMAL AWARD SUPPLEMENTAL PAGE Case No.: ______________________________ Vicinage: ______________________________ ADDITIONAL CARRIERS NAME: ADDRESS: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE:: FROM: TO: NAME: ADDRESS: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE:: FROM: TO: GUARDIAN OR REPRESENTATIVE NAME: ADDRESS: RELATIONSHIP TO PETITIONER: INDIVIDUAL CORPORATE OFFICERS/PARTNERS/LLC MEMBERS NAME: ADDRESS: NAME: ADDRESS: