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Get NJ WC-367 2015-2024

IAL SECURITY OR IDENTIFICATION NUMBER: ATTORNEY FOR RESPONDENT PETITIONER State of New Jersey Department of Labor and Workforce Development Division of Workers’ Compensation PO Box 381 Trenton, New Jersey 08625-0381 WC-367 r. 5/4/2015 TELEPHONE NUMBER: FAX NUMBER: VS INSURANCE CARRIER or SELF-INSURED ENTITY NAME: ADDRESS: CORRECT NAME OF RESPONDENT IF INCORRECT ON CLAIM PETITION: Petitioner was in employment on date alleged in petition: YES □ NO □ Correct date of accident or .

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