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LWD Home > Workers' Compensation > Forms & Publications

Forms & Publications

The majority of the forms available on our website are available in Adobe Acrobat acrobat image (PDF) format. Some are also available in Microsoft Word format. To view and print PDF forms, you must have Adobe Acrobat Reader which is a free download from Adobe. Click here to download free software.

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: interactive. 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

1/16/20 N.J.S.A 34:15-95.6 Worksheet for Supplemental Benefit Calculations
12/20/19 Dependency Claim Petition -To Convert Voluntary Tender to Formal Judgment
12/20/19 Hearing Cycle Calendar
12/19/18 2020 Schedule of Disabilities


 

   

BROCHURES AND PUBLICATIONS  

Doc # Word  PDF
acrobat
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
acrobat
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
interactive
9/07
 
EMPLOYER/INSURANCE CARRIER FORMS   Doc # Word  PDF
acrobat
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
acrobat
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 
interactive
PDF
interactive
3/07 
Standard petitioner's occupational interrogatory form:   wc-22   PDF
 
* Second Injury Fund Verified Petition (fillable):   scf-161_i Word
interactive
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
interactive
PDF
interactive
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
interactive 
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
interactive 
PDF
interactive
12/07
* Trial Scheduling Order (fillable): wc-16   PDF
interactive
6/07
* Second Injury Fund Information Review Sheet (fillable): wc-380 Word
interactive
  6/08
 
SETTLEMENT FORMS  Doc # Word  PDF
acrobat
Version
Date
 
* Judgment / Order Approving Settlement (fillable):    (with Case Exhibit Listing) WC-100i   PDF
interactive
9/23/15
* Order for Dismissal (fillable):    WC-100Dismissal_i Word
interactive
PDF
interactive
7/13
* Generic Order (for Miscellaneous Decisions, Motions, etc.): (fillable)  WC-100Generic Word
interactive
PDF
interactive
7/13
* Order Approving Settlement under NJSA 34:15-20:  (fillable) (page 1 and 2) WC-370_i Word
interactive
PDF
interactive
4/13
* Amended Order:  (fillable) wc-8   PDF
interactive
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
interactive
PDF
interactive
9/15
* Order for Total Disability with SS Offset (fillable):       wc-375_i Word
interactive
PDF
interactive
12/15
* Order for Total Disability with SIF (fillable):       wc-376_i   Word
interactive
PDF
interactive
12/15
*Addendum to Order for Total Disability (fillable):    wc-377_i   Word
interactive
PDF
interactive
12/15
 
SCHEDULES OF DISABILITIES  Doc # Word  PDF
acrobat
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
acrobat
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
interactive
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
interactive
PDF
interactive

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
 interactive



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 
interactive
PDF 
interactive

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
acrobat
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
interactive
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
interactive
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
interactive
1/2020
Public Sector Contact Listing:
Similar to above listing.
    PDF
5/3/18
Hearing Cycle Calendar     PDF 12/19

 

 



 

 

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