N.J. Admin. Code § 12:235-5.3

Current through Register Vol. 56, No. 8, April 15, 2024

Section 12:235-5.3 - Filing

(a) The verified petition for benefits shall be filed in accordance with 34:15-95.1 and shall include a succinct and accurate description of all medical, legal and factual basis upon which the petitioner alleges eligibility for Fund benefits pursuant to 34:15-95. The verified petition shall be under oath or affirmation and be accompanied by all physician's reports in possession of the applicant or the applicant's attorney.

(b) The verified petition shall also include the following:

1. Name and address of petitioner;

2. Social security number of petitioner;

3. Age and date of birth of petitioner;

4. Marital status and educational background of petitioner;

5. A summary of petitioner's employment history;

6. A description of disabilities which existed prior to the date of the last compensable injury, and the date of onset of each;

7. The last compensable injury, indicating the date and a description of the occurrence; a description of the injury; brief description of the medical treatment for the injury; a description of permanent injury; name and address of employer and its insurance carrier; petitioner's wages and compensation rate; and a listing of all compensation paid to date for this injury;

8. An indication as to whether a third party tort claim has been made as to the last compensable injury, stating the name and address of the third party and the status of the claim;

9. A copy of all reports which are in the possession or control of the party filing the applications from all proposed expert witnesses and all treating physicians;

10. A description of all wage replacements presently being received by the petitioner;

11. References to all prior allowances and awards in workers' compensation matters concerning the petitioner, including the date of the accident and the extent of the allowance or award.

(c) Respondent shall provide all evaluative reports to the Second Injury Fund at the first motion hearing.

N.J. Admin. Code § 12:235-5.3

Amended by R.1991 d.466, effective 9/3/1991.
See: 23 New Jersey Register 1759(a), 23 New Jersey Register 2642(a).
Stylistic changes.
Amended by R.1997 d.110, effective 3/3/1997.
See: 28 New Jersey Register 4067(a), 29 New Jersey Register 799(a).
Added (c).
Recodified from N.J.A.C. 12:235-7.4 by R.2002 d.340, effective 10/21/2002.
See: 34 New Jersey Register 2257(a), 34 New Jersey Register 2549(a), 34 New Jersey Register 3641(d).
Former N.J.A.C. 12:235-5.3, Other motions, recodified to N.J.A.C. 12:235-3.3.