Get Employee Claim Petition - Department Of Labor And Workforce ... - Lwd Dol State Nj

This guide provides essential instructions for users to effectively complete the Employee Claim Petition for the New Jersey Department of Labor and Workforce Development. By following this comprehensive step-by-step approach, individuals can confidently navigate the online form.

Follow the steps to successfully complete the form online.

1. Select the ‘Get Form’ button to access the Employee Claim Petition form and open it for editing.
2. Indicate whether this is a new filing or an amended filing by checking the appropriate box.
3. If filing an amended claim, enter the case number and vicinage in the provided fields.
4. Complete the 'Petitioner Social Security Number' section. If applicable, check the box indicating 'SSN Not Available.'
5. Provide the name and address of the petitioner and any attorney representing them.
6. Fill in the date of birth, sex, telephone number, and fax number of the petitioner.
7. Indicate if a guardian or representative is filing on behalf of the petitioner, checking the relevant box.
8. Enter the employer's name and address, along with the insurance carrier or self-insured entity's name.
9. If the employer is known by a different name, please provide that information.
10. Specify the employer's status (insured, uninsured, self-insured private, or self-insured government agency) and the period of coverage.
11. Detail the injury and employment information including the date of the accident, where the injury occurred, and how it occurred.
12. Describe the extent and character of the injury, including any amputation or disability.
13. Complete the dates for when work was stopped and when it was returned, alongside the date the injury was reported and to whom.
14. Input the gross wages and the wage period, as well as details regarding temporary compensation and permanent disability paid.
15. Indicate if the employer furnished medical aid and respond to questions regarding Medicare and Medicaid eligibility.
16. Provide any additional important facts and a summary of changes only if filing an amended petition.
17. Sign the petition, and ensure it is subscribed and sworn or affirmed as required.
18. After completing the form, save your changes, and consider downloading, printing, or sharing the form as needed.

Complete your Employee Claim Petition online today to ensure a timely submission.