Official Site of The State of New Jersey
"Why Did I Get This?" - Form Look Up
Did you get a form or notice in the mail, but aren't sure what it means?
This page lists all Temporary Disability and Family Leave Insurance forms that may be sent to you, why you may have received them, and what to do once you get one.
We provide this form online to get information from you, or update information you already gave us. For example:
- If you file a Temporary Disability Insurance claim, and tell us that you applied for or received Social Security disability benefits from the federal government
- If your Social Security number cannot be verified
- If you file a Family Leave Insurance claim for bonding and need to show proof of your relationship to the baby or child
- If you file a Family Leave Insurance claim for intermittent days
What do I do with this form?
Answer all questions clearly and make clear copies of all requested documents. We need this information to process your claim. Sign and date the form, and fax it to 609-984-4138. If you don’t, your application may be denied.
Once your claim has been entered into our system, we automatically send this form to you. You need to send it back only if anything has changed since you filed. For example, if you moved to a new address, or recovered and returned to work, you need to let us know.
What do I do with this form?
If you have information to update, fill out that section of the form. Sign and date the form, and fax it to 609-984-4138. Otherwise, keep the form in a safe place to use for future changes.
We send this form if your application is missing information, or if the information you provide doesn’t match the statement of your medical provider and/or employer. We will tell you which question(s) you need to re-answer.
What do I do with this form?
Answer all questions clearly. We need this information to process your application. Sign and date the form, and fax it to 609-984-4138. If you don’t, your claim may be denied.
If you receive your Temporary Disability Insurance benefits via check instead of a Money Network/New Banking Direct debit card, this form will be attached to the check. It explains that if you have recovered or returned to work, or if you were not entitled to benefits for any time during this period, you should not cash the check.
What do I do with this form?
Review the time period that the benefits cover and make sure that you are entitled to the money. Keep this form for your records. If you were paid in error, follow the instructions for returning the check to the division.
If we have not received your recovery or return-to-work date within 90 days of the last Temporary Disability Insurance benefit payment posted, we send you this form. It will ask if you have recovered or returned to work so that we can close your claim.
What do I do with this form?
If applicable, fill out the date you recovered or returned to work. Sign and date the form, and fax it to 609-984-4138. If you haven’t recovered or returned to work, you should send in additional medical information to extend your benefits.
If you update your home or mailing address via the online address change application, this notice is automatically mailed to you.
What do I do with this form?
If the infromation is correct, no further action is needed from you. If the address listed on the notice is incorrect, please contact the Customer Service Section at: 609-292-7060.
Good news! Your Temporary Disability or Family Leave Insurance claim was approved. Read both sides of the form. The front page has important information about your benefits, including:
- Your chargeable employer (the last employer you worked for, or were paid by)
- Your weekly benefit rate (how much money you’ll get per week)
- Your maximum benefit amount (the most money you could possibly receive on this claim)
The back of the form has general information about the payment schedule, taxes, and reasons why benefits could be reduced.
What do I do with this form?
Keep the form for your records. Refer to it if you have questions regarding payments. If you disagree with your weekly benefit rate and want to file an appeal, follow the instructions on the form.
This form notifies your chargeable employer that your application has been approved. This form has important information about your benefits and lists the payment schedule, taxes, and reasons benefits could be reduced.
What do I do with this form?
There is no action for you to take on this form. Your employer should keep this for their records and refer to it if they have questions regarding your application.
We send this notice when your Temporary Disability or Family Leave Insurance application is not approved. The front page lists the reason your application was denied. Applications denied due to lack of information may be reconsidered after you provide the missing information. The back of the form has general information about the approval process and your appeal rights.
What do I do with this form?
Keep the form for your records. Refer to it if you have questions regarding your application. If you choose to appeal the decision, follow the instructions on the back of the form. If your claim was incomplete, fax the missing information to 609-984-4138. Include your Social Security number on all pages.
We send this notice to your employer if your application is not approved. The front page explains why your claim was denied. The back of the form gives general information regarding the approval process and the employer’s appeal rights.
What do I do with this form?
There is no action for you to take on this form. Your employer should keep it for their records and refer to it if they have questions regarding your application. If you choose to appeal the decision, follow the instructions on the form.
We rely on you to provide all employment history on your application, and we verify your statement against the quarterly earnings that your employer (or former employer) reported to the state. In the event that we do not have enough information to approve your claim based on the reported calendar earnings and your statement, your employer may be required to provide information. If your employer receives this form, it means:
- information was missing from the original application, and/or
- the information on the application conflicted with wage record and/or
- we need to clarify your employment information.
What do I do with this form?
There is no action for you to take. Your employer must answer all questions on both sides of the form. Sign and date the form, and fax it to 609-984-4138 within 10 days of the mailing date shown. Employers who fail to comply may face a monetary penalty.
We rely on you to provide all employment history on your application, and we verify your statement against the quarterly earnings that your employer (or former employer) reported to the state. In the event that we do not have enough information to approve your claim based on the reported calendar earnings and your statement, your employer may be required to provide information. If your employer receives this form, it means:
- information was missing from the original application, and/or
- the information on the application conflicted with wage record and/or
- we need to clarify your employment information.
What do I do with this form?
There is no action for you to take. Your employer must answer all questions on both sides of the form. Sign and date the form, and fax it to 609-984-4138 within 10 days of the mailing date shown. Employers who fail to comply may face a monetary penalty.
We send this form to your employer to check if your earnings meet the minimum annual wage requirement for Temporary Disability or Family Leave Insurance. For claims beginning in 2024, you must have either:
- earned a gross of at least $14,200 or
- earned at least $283/week for 20 weeks
during the base year period.
What do I do with this form?
There is no action for you to take on this form. Your employer must report the gross earnings for each calendar week listed on the form, and fax it to 609-984-4138 within 10 days of the mailing date. Employers who fail to comply may face a monetary penalty.
We send this notice to employers who do not respond to our written requests for information within 10 days of mailing. New Jersey law requires that your employer must provide your wage and employment information in a timely fashion or face a penalty. A $250 penalty has been assessed to their account.
What do I do with this form?
There is no action for you to take on this form.
If we have not been notified of a recovery or return-to-work date within 60 days of the last Temporary Disability Insurance payment posted, we will send your employer this form to close out your claim.
What do I do with this form?
Your employer will enter your return to work date, if applicable. They should sign and date the form, and fax it to 609-984-4138.
If you receive your Family Leave Insurance benefits via check instead of a Money Network/My Banking Direct debit card, this form will be attached to the check. It explains that if you have returned to work, or if you were not entitled to benefits for any time during this period, you should not cash the check.
What do I do with this form?
Review the time period that the benefits cover and make sure that you are entitled to the money. Keep this form for your records. If you were paid in error, follow the instructions for returning the check to the division.
If you received Temporary Disability Insurance benefits from the state for your pregnancy and postpartum recovery, we will send this form after you notify us of your delivery date. It will tell you how to apply for Family Leave Insurance benefits for bonding.
What do I do with this form?
If you want to apply for Family Leave Insurance benefits immediately after your Temporary Disability Insurance benefits end, follow the instructions on the form. The form has a unique Online Form ID number for you to use when applying online.
If you do not claim your maximum duration of Family Leave Insurance benefits when you initially apply, we will send this form so you can get benefits for the remaining days, if eligible.
What do I do with this form?
Complete Part A of the form and provide the date through which you wish to receive benefits. Complete the schedule on the reverse side of the form, showing the days you did not work and wish to claim Family Leave Insurance benefits. Week Beginning Date should be the Sunday of the week you are taking leave. No benefits will be approved beyond the date of your signature. For caregiving claims only, have the care recipient’s healthcare provider complete Part B. Fax the form to 609-984-4138.
After you complete your portion of an online application, you will be prompted to download and print the Medical Certificate (M01) form to take to your medical provider. This form includes instructions and a unique Online Form ID number so your medical provider can complete the medical certificate online.
What do I do with this form?
Print the form and bring it to your medical provider. If you receive a denial notice before the medical certificate is submitted online, your medical provider will need to print out and complete a medical statement (Part C of the application) and fax it to 609-984-4138.
We send this form if your application is missing medical information, if the medical information needs further review, or if your statement conflicts with your medical provider’s statement. We will tell you which question(s) your medical provider needs to re-answer.
What do I do with this form?
We need this information to process your application. Your medical provider will have to answer all questions clearly, sign and date the form, and fax it to 609-984-4138. If your medical provider does not comply, your application may be denied.
Typically, an obstetrician will recommend that an expectant mother stop working four weeks before her estimated delivery date, and remain out of work for up to six weeks after a vaginal birth, and up to 8 weeks after a C-section delivery. If your medical provider certifies your disability beyond this time frame (on either end) and does not list a disabling complication, we will request proof of one. We will not pay benefits outside this standard range unless the mother experiences a disabling complication. NOTE: The complication must be current to this pregnancy and affect the mother’s health in some way. It does not apply to complications experienced only by the baby before or after birth.
What do I do with this form?
We need this information to process your application. Your medical provider will have to answer all questions clearly, sign and date the form, and fax it to 609-984-4138. If your medical provider does not comply, your claim may be denied.
Approved medical providers receive this form when we need them to perform an independent medical exam on the person listed in Box 5.
What do I do with this form?
Perform the requested exam on the appointment date listed in Box 14. Fax your findings to us at 609-292-1692 within seven days of the appointment. Keep the form for your records.
Our medical review unit wants you to have an independent medical exam with an agency-approved medical provider. This does not affect the relationship between you and your own doctor, or your treatment. The findings are confidential and will be used only to process your application.
What do I do with this form?
Attend the appointment on the date listed. If you don’t, your application may be denied. If you have questions about this impartial medical exam, direct them to the phone number listed on this form. Keep the form for your records.
We send this form if a part of your claim is not payable. Reasons may include that you got paid time off from your employer, or that you owed us money from benefits that were previously overpaid.
What do I do with this form?
Keep the form for your records. Contact us if you disagree with the notice.
We send this form if your benefits have been reduced. Reasons may include that you got paid time off or a pension payment from your most recent employer.
What do I do with this form?
Keep the form for your records. Contact us if you disagree with the notice.
We send this notice before issuing your last authorized benefit payment.
What do I do with this form?
If you are still disabled after the date in Box 9, use the unique Online Form ID number to file an extension online. Print the confirmation page and give it to your medical provider to complete your medical certification online. If you have recovered or returned to work, end your claim online using the unique Online Form ID number.
We mail this form in the unfortunate event that the person who applied for Temporary Disability or Family Leave Insurance benefits has passed away. It explains how that person’s estate can claim any benefits to which it may be entitled.
What do I do with this form?
We need notarized copies of the following documents to issue benefits to an estate:
- the claimant’s death certificate, and
- an affidavit issued by the Surrogate of the county in which the claimant resided, and
- the signed affidavit (Form P40) provided by this agency.
Send these notarized documents and the completed Instructions for Claiming Benefits Due to a Deceased Person (P40) form you received to: Division of Temporary Disability Insurance, PO Box 387, Trenton, NJ 08625-0387.
We send this form if you were overpaid due to a false statement or representation, or your failure to disclose a material fact. For example, if you returned to work, but filed an extension of your claim stating you were still disabled, that would be a false statement or representation. This form tells you how to repay those benefits in addition to any fines that may be owed.
What do I do with this form?
Follow the instructions to repay the debt. You can repay the debt in full by sending a check to the division, or you can set up an installment plan. The back of the form explains how to proceed with either option. If you wish to appeal the overpayment, follow those instructions on the back of the form.
We send this form if you were improperly paid benefits. It shows the period(s) that should not have been paid and the amount overpaid.
What do I do with this form?
Follow the instructions to repay the debt. You can repay the debt in full by sending a check to the division, or you can set up an installment plan. The back of the form explains how to proceed with either option. If you wish to appeal the overpayment, follow the instructions on the back of the form.
We send this form if we don’t receive the Request to Claimant for Identity Validation (V01).
What do I do with this form?
Make clear black-and-white photocopies (not printouts of a mobile phone picture) of the following documents:
- photo identification (such as driver’s license, U.S. passport, military ID card) with date of birth, and
- a copy of your Social Security card, and
- a bill or other piece of mail showing your current home and mailing address (if different), and
- four of the most recent paystubs from all employers that you worked for in the last 18 months prior to your first day of leave.
Fax the completed form (including your signature and the date) and supporting identity validation documents only to the fax number listed on the form.
If you apply online for Temporary Disability Insurance benefits and tell us that your injury or illness is work-related, even by mistake, you will be prompted to print a two-part form.
What do I do with this form?
If your illness or injury was NOT work-related:
If you told us in error that your injury or illness is work-related and will not be applying for Workers’ Compensation benefits, you must confirm this in writing. Sign and date the bottom of the W01 form and fax it to 609-984-4138. Once we receive your signed form, we can process your regular Temporary Disability Insurance claim. You can disregard the second part of the form.
If your illness or injury WAS work-related:
You must first file an application with your Worker’s Compensation insurance. If you are denied benefits and appeal the decision, you may qualify for Temporary Disability Insurance benefits while your appeal is being decided. You must agree to pay back these benefits if the appeal is decided in your favor and you are awarded Workers’ Compensation benefits. In that case, fill out only the Certification of Contested Workers’ Compensation Claim form (DS-221). You must sign and date the subrogation agreement at the bottom of the form.
If you apply for Temporary Disability Insurance benefits by mail or fax and tell us that your injury or illness is work-related, even by mistake, you will be mailed a W10 form and a DS-221 form, Certification of Contested Workers’ Compensation Claim.
What do I do with this form?
If your illness or injury was NOT work-related:
If you told us by mistake that your injury or illness is work-related and will not be filing a Workers’ Compensation claim, you must affirm this in writing. Sign and date the bottom of the W10 form and fax it to 609-984-4138. Once we receive your signed form, we can process your regular Temporary Disability Insurance claim. You can disregard the DS-221.
If your illness or injury WAS work-related:
You must first file an application with your Worker’s Compensation insurance. If you are denied benefits and appeal the decision, you may qualify for Temporary Disability Insurance benefits while your appeal is being decided. You must agree to pay back these benefits if the appeal is decided in your favor and you are awarded Workers’ Compensation benefits. In this case, fill out only the Certification of Contested Workers’ Compensation Claim (DS-221). You must include the claim petition number, the Workers’ Compensation carrier name and address, and sign and date the agreement at the bottom of the form. Fax the completed form to 609-984-4138
We send this notice if a lien is filed against your Workers’ Compensation benefits. It helps us get reimbursed if you win a settlement.
What do I do with this form?
The total amount of the lien will be verified when your case is decided. If you disagree with this arrangement, follow the instructions on this form to file an appeal. Keep the form for your records.
