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A NOTE ABOUT INTERACTIVE / FILLABLE FORMS: Many of the forms listed below can be filled out electronically and saved to your local drive. They are denoted by an asterisk and this image: . Please note that interactive Word forms do not convert properly into other word processsing software. Users that do not have Microsoft Word should use the PDF versions of these forms.   For further instructions and helpful hints on using interactive forms, click here.

FORMS MENU:		RECENT UPDATES:
Brochures & Publications  Task Force Reports   Employee/Worker Forms  Employer/Insurance Carrier Forms  Litigation Forms       Petitioner       Respondent       Petitioner & Respondent       Settlement Orders  Schedule of Disabilities  E-Calendars, COURTS on-line  and E-Filing  Miscellaneous		4/8/21 Order To Convert Dependency Voluntary Tender to Formal Judgment 4/8/21 N.J.S.A 34:15-95.6 Worksheet for Supplemental Benefit Calculations 1/1/21 2021 Schedule of Disabilities 12/20/19 Dependency Claim Petition -To Convert Voluntary Tender to Formal Judgment

BROCHURES AND PUBLICATIONS		Doc #	Word	PDF	Version Date
	Workers' Compensation Statute		Word	PDF	6/13/13
	Workers' Compensation Rules		Word	PDF	1/15/13
	A Workers' Guide to Workers' Compensation in New Jersey:  (legal size paper)	wc(g)-338		PDF	1/16
	Guia Interpretativa para el Trabajador A la Ley de Compensacion al Trabajador en Nueva Jersey:   (legal size paper)	wc(g)-338s		PDF	1/16
	Uninsured Employers Fund Pamphlet:     Provides the regulations associated with the Uninsured Employers Fund (legal size paper)	scf-122		PDF	11/02
	Second Injury Fund- A Beneficiary's Guide: Provides necessary information to recipients of second injury fund benefits. (legal size paper)	scf-103		PDF	1/11
	Fondo De Segunda Incapacidad - Guia del Beneficiario	scf-103s		PDF	1/11
	WC Research Manual - link to the instructions page				7/11
EMPLOYEE/WORKER FORMS		Doc #	Word	PDF	Version Date
	Application for Informal Hearing:	wc-66		PDF	6/06
	Discrimination Complaint Form:	scf-4		PDF	7/04
	* Report of Non-Compliance (fillable): Submit this form to report an uninsured employer	scf-528		PDF	9/07
EMPLOYER/INSURANCE CARRIER FORMS		Doc #	Word	PDF	Version Date
	IA-1 First Report of Injury (FROI):  Document maintained by the International Association of Industrial Accident Boards & Commissions (IAIABC).			PDF
	IA-2 Subsequent Report of Injury form (SROI): Document maintained by the International Association of Industrial Accident Boards & Commissions (IAIABC).			PDF
	NJ Benefit Letter - Medical Only:  Document maintained at the Compensation Rating and Bureau (NJCRIB) website.			PDF
	NJ Benefit Letter - Indemnity:  Document maintained at the Compensation Rating and Bureau (NJCRIB) website.			PDF	10/7/04
	NJ Benefit Letter Usage Directions:  Document maintained at the Compensation Rating and Bureau (NJCRIB) website.			PDF	10/7/04
	Employer Notice of Workers' Compensation Insurance Coverage:  This link will take you to the NJ Compensation Rating & Inspection Bureau's website.			PDF
FORMAL LITIGATION FORMS		Doc #	Word	PDF	Version Date
PETITIONER FORMS
	Employee's Claim Petition (can be used for Amended CP)	wc-365		PDF	8/26/15
	Employee's Claim Petition Supplemental Page:	wc-365.1		PDF	5/7/15
	Application for Review or Modification of Formal Award (can be used for Amended ReOpener):      - ReOpener Supplemental Page	wc-368 wc-368_Supp		PDF PDF	8/26/15
	Dependency Claim Petition (can be used for Amended DCP):     - DCP Supplemental Page	wc-366 DWCsupp		PDF PDF	8/26/15
	Dependency Claim Petition To Convert Voluntary Tender to Formal Judgment	wc-956		PDF	12/19
	* Notice of Motion for Temporary and/or Medical Benefits (fillable):	wc-101_i	Word	PDF	3/07
	Standard petitioner's occupational interrogatory form:	wc-22		PDF
	* Second Injury Fund Verified Petition (fillable):	scf-161_i	Word	PDF	10/10/07
	Social Security Offset Calculation:	scf-16		PDF	5/95
	Medical Provider Application for Payment or Reimbursement of Medical Payment:	wc-381		PDF	8/26/15
	Uninsured Employer's Fund Information Packet			PDF	9/7/07
	Motion for Emergent Medical Treatment	wc-383		PDF	5/14
	Application for Commutation:	wc-60		PDF	6/07
RESPONDENT FORMS
	Respondent's Answer to Claim Petition (can be used for Amended Answer):	wc-367		PDF	5/15
	Respondent's Answer to Application for Review & Modification of Formal Award (can be used for Amended Answer):	wc-369		PDF	6/15
	Respondent's Answer to Dependency Claim Petition:	wc-171		PDF	7/04
	* Answering Statement for Motion for Medical and/or Temporary Benefits (fillable):	wc-170	Word	PDF	3/07
	Respondent's Answer to Medical Claim Petition			PDF	7/10
	Standard respondent's occupational interrogatory form:	wc-23		PDF
PETITIONER & RESPONDENT FORMS
	* Request for Adjournment / Ready Hold  - page 1 (fillable):  * Request for Adjournment / Ready Hold - additional page ** Open form and enter in your firm name and contact info. Save the form onto your computer by hitting Save As. Use the saved form as a template for future Adjournment Requests.  This form can now be e-mailed to the individual district offices. Follow  instructions on the form.			page1 page2	6/30/16
	Substitution of Attorney:	wc-10		PDF	8/04
	Subpoena Duces Tecum Ad Testificandum:	wc-18		PDF	4/06
	Subpoena Ad Testificandum:	wc-18.1		PDF	4/06
	Subpoena Duces Tecum:	wc-18.2		PDF	4/06
	Request for Social Security Information:	wc-124		PDF	6/04
	Pre-Trial Memorandum:	wc-31		PDF	5/12
	* Notice of Motion (fillable):	wc-7	Word	PDF	12/07
	* Trial Scheduling Order (fillable):	wc-16		PDF	6/07
	* Second Injury Fund Information Review Sheet (fillable):	wc-380	Word		6/08
SETTLEMENT FORMS		Doc #	Word	PDF	Version Date
	* Judgment / Order Approving Settlement (fillable):    (with Case Exhibit Listing)	WC-100i		PDF	9/23/15
	* Order for Dismissal (fillable):	WC-100Dismissal_i	Word	PDF	7/13
	* Generic Order (for Miscellaneous Decisions, Motions, etc.): (fillable)	WC-100Generic	Word	PDF	7/13
	* Order Approving Settlement under NJSA 34:15-20:  (fillable) (page 1 and 2)	WC-370_i	Word	PDF	4/13
	* Amended Order:  (fillable)	wc-8		PDF	8/09
	Order for Distribution (for child support):	wc103 - wc103.1		PDF	4/06
	Order for Distribution of Temporary Award (for child support):	wc379 - wc379.1		PDF	4/06
	Affidavit of Dependent in Support of Settlement Under N.J.S.A. 34:15-20	wc-366.1		PDF	9/9/05
	Decision of Dismissal (Second Injury Fund):	wc-47		PDF	1/17
	* Order for Total Disability (fillable):	wc-374 _i	Word	PDF	9/15
	* Order for Total Disability with SS Offset (fillable):	wc-375_i	Word	PDF	12/15
	* Order for Total Disability with SIF (fillable):	wc-376_i	Word	PDF	12/15
	*Addendum to Order for Total Disability (fillable):	wc-377_i	Word	PDF	12/15
	Order to Convert Dependency Voluntary Tender to Judgment (fillable):	O-956_i		PDF	3/21
SCHEDULES OF DISABILITIES		Doc #	Word	PDF	Version Date
	Calendar Year 2002			PDF
	Calendar Year 2003			PDF
	Calendar Year 2004			PDF
	Calendar Year 2005			PDF
	Calendar Year 2006			PDF
	Calendar Year 2007			PDF
	Calendar Year 2008			PDF
	Calendar Year 2009			PDF
	Calendar Year 2010			PDF
	Calendar Year 2011			PDF
	Calendar Year 2012			PDF
	Calendar Year 2013			PDF
	Calendar Year 2014			PDF
	Calendar Year 2015			PDF
	Calendar Year 2016			PDF
	Calendar Year 2017			PDF
	Calendar Year 2018			PDF
	Calendar Year 2019			PDF
	Calendar Year 2020			PDF
	Calendar Year 2021			PDF
ELECTRONIC CALENDARS, COURTS ON-LINE AND ELECTRONIC FILING FORMS		Doc #	Word	PDF	Version Date
Electronic Calendars
	* Attorney Calendar E-mail Program application (fillable):   This form initiates the transmission of  "Attorney Calendar" scheduling notices via e-mail to designated e-mail address(es).			PDF	2/10/16
COURTS on-line
	* COURTS on-line Internet Access Application (fillable):   This application package needs to be completed if a law firm, insurance carrier or self-insured is interested in accessing COURTS on-line, the Division's on-line case management website. Package contains both the Designation of Contact form and Subscriber application form.		Word	PDF	9/5/12
	Subscriber Application only (fillable):   This form needs to be completed if a law firm, insurance carrier or self-insured is interested in adding an additional subscriber to access COURTS on-line and the firm has already established a Contact Person with the Division. This form must be signed by both the subscriber and the firm’s Contact Person prior to submitting.			PDF	9/5/12
	*COURTS on-line Subscriber Change Form (fillable):   This form needs to be completed if an existing COURTS on-line subscriber has had a change to their name or e-mail address or if their e-filing access level request has changed. The form must be signed by the firm's Contact Person prior to submitting.		Word	PDF	7/19/13
Electronic Filing
	E-Filing Procedures Guide			PDF	6/26/12
	E-Filing Motions Procedures Guide			PDF	7/16/14
MISCELLANEOUS FORMS		Doc #	Word	PDF	Version Date
	Uninsured Employer's Fund Information Packet			PDF	9/7/07
	Request for Records Inspection: This form must be completed and signed before the Division can release records.	wc-147		PDF	6/2014
	* Report of Non-Compliance (fillable):   This form may be used by any individual or organization to report allegations of failure on the part of an employer to maintain workers' compensation insurance coverage or obtaining authorization to self-insure.	scf-528		PDF	9/07
	* Insurance Carrier Contact form (fillable): This form to designate a contact person must be completed by every insurance carriers and self-insurer authorized to do business in NJ.			PDF	2/17/17
	Insurance Carrier/ Self-Insurer Contact Listing:   These individuals can be contacted by judicial staff and attorneys where there has been no appearance or formal response made by the carrier or their counsel on pending Motions for Medical and Temporary Benefits.			PDF	5/3/18
	N.J.S.A 34:15-95.6 Worksheet for Supplemental Benefit Calculations (fillable):			PDF	1/2020
	Public Sector Contact Listing: Similar to above listing.			PDF	5/3/18
	Hearing Cycle Calendar			PDF	12/19