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Get NJ WC-365 2015-2024

G SOCIAL SECURITY NUMBER: â–¡ â–¡ Vicinage: ______________________________ **please enter above only if filing an Amended Claim** TAX IDENTIFICATION NUMBER: NAME: ATTORNEY FOR PETITIONER PETITIONER AMENDED FILING SSN Not Available NAME: ADDRESS: DATE OF BIRTH: â–¡ Case No.: ______________________________ SEX: ADDRESS: TELEPHONE NUMBER: FAX NUMBER: A guardian or other representative is filing on behalf of the petitioner. See Supplemental Page for details. vs NAME: INSURANCE C.

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