N.J. Admin. Code § 12:235-14.1

Current through Register Vol. 56, No. 11, June 3, 2024

Section 12:235-14.1 - Listing of forms

(a) Listed below are the titles and numerical designations of the standard forms utilized for workers' compensation:

1. Employee Claim Petition, WC 365;

2. Dependency Claim Petition, WC 366;

3. Application for Review or Modification of Formal Award, WC 368;

4. Notice of Motion for Temporary and/or Medical Disability Benefits, WC 101;

5. Respondent's Answer to Claim Petition, WC 367;

6. Respondent's Answer to Dependency Claim Petition, WC 171;

7. Answer to Application for Review or Modification of Formal Award, WC 369;

8. Answering Statement to Motion for Temporary and Medical Benefits, WC 102;

9. Standard Respondent's Interrogatories: Occupational Diseases, WC 22;

10. Standard Petitioner's Interrogatories: Occupational Diseases, WC 23;

11. Pre-Trial Memorandum, WC(DO) 31;

12. Order Approving Settlement WC(DO) 370;

13. No Insurance Case, WC(DO) 339;

14. Bench Referral from Division of Workers' Compensation to New Jersey Division of Vocational Rehabilitation Services;

15. Application for Informal Hearing, WC(CF)-66;

16. Central Office Record of Informal Proceedings, WC(CF)-11;

17. Second Injury Fund Verified Petition (SCF-161);

18. Decision of Eligibility, WC-48;

19. Application for Commutation, WC(1)-60;

20. Decision of Dismissal, WC-47;

21. Discrimination Complaint SCF 4;

22. Employer's First Report of Accidental Injury of Occupational Illness, L&I 1;

23. Employer's First Report to Division of Workers' Compensation of Accidental Injury or Occupational Disease, WC-1;

24. Insurer's Initial Notice of Accident and Insurer's and Self-Insurer's Statement of Wages and Agreement to Care for Case, WC-2;

25. Informational Brochure on Informal Proceedings.

N.J. Admin. Code § 12:235-14.1

Amended by R.1997 d.110, effective 3/3/1997.
See: 28 New Jersey Register 4067(a), 29 New Jersey Register 799(a).
Amended form references throughout section; rewrote (a)10.
Amended by R.1998 d.152, effective 3/16/1998.
See: 30 New Jersey Register 18(a), 30 New Jersey Register 1047(b).
In (a)4, substituted "and/or Medical Disability" for "and Medical"; in (a)9, added ", WC 22"; and in (a)10, added ", WC 23".
Amended by R.1998 d.550, effective 11/16/1998.
See: 30 New Jersey Register 3155(a), 30 New Jersey Register 4055(a).
In (a), deleted "Application and" and inserted "(SCF-161);" in 17.
Amended by R.1998 d.576, effective 12/7/1998.
See: 30 New Jersey Register 3588(a), 30 New Jersey Register 4244(b).
In (a), added 30.
Amended by R.2002 d.340, effective 10/21/2002.
See: 34 New Jersey Register 2257(a), 34 New Jersey Register 3641(d).
In (a), rewrote 25 and deleted 26 through 30.