Form WC(CF)-66 "Application for Informal Hearing" - New Jersey

What Is Form WC(CF)-66?

This is a legal form that was released by the New Jersey Department of Labor & Workforce Development - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2006;
  • The latest edition provided by the New Jersey Department of Labor & Workforce Development;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form WC(CF)-66 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Labor & Workforce Development.

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Download Form WC(CF)-66 "Application for Informal Hearing" - New Jersey

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State of New Jersey
FOR STAFF USE ONLY
APPLICATION
Department of Labor and Workforce Development
FOR
Division of Workers’ Compensation
CASE NO: ________________________
PO Box 381
INFORMAL HEARING
Trenton, NJ 08625-0381
VICINAGE: _______________________
WC(CF)-66 (R-2-06)
NEW
ORIGINAL INFORMAL CASE #
AMENDED
SOCIAL SECURITY NUMBER
EMPLOYER
EMPLOYEE
ADDRESS (Including County)
ADDRESS (Including County)
INSURANCE CARRIER
TELEPHONE NUMBER
ADDRESS
DATE OF BIRTH
Name of the Insurance Company can be obtained either from the Employer or by writing to the Compensation Rating and Inspection
Bureau 60 Park Place, Newark, New Jersey 07102 (BE SURE TO INCLUDE A SELF-ADDRESSED STAMPED ENVELOPE)
Date of Accident
Type of Injury
Hearing Requested by:
EMPLOYEE (PETITIONER)
EMPLOYER
INSURANCE CARRIER
PETITIONERS ATTORNEY: If checked, please provide Name and Address of Attorney:
NAME:
ADDRESS:
TELEPHONE NUMBER:
WERE YOU ELIGIBLE FOR MEDICAID BENEFITS AT THE TIME OF THE ACCIDENT?
YES
NO
DID YOU BECOME ELIGIBLE FOR MEDICAID BENEFITS AFTER THE ACCIDENT?
YES
NO
YOU ARE ADVISED THAT MEDICAID PAYMENTS RELATED TO THE ACCIDENT ARE TO BE PAID IN ACCORDANCE
WITH N.J.S.A. 30:14-1, et. seq.
IMPORTANT:
This proceeding will not prevent the Statute of Limitations from expiring. FAILURE TO FILE A
FORMAL PETITION within two years of the date of accident or the last payment and / or authorized
medical treatment by the employer’s insurance carrier can bar any action on a claim filed after that time.
TO INSURE IMMEDIATE PROCESSING,
PLEASE COMPLETE THIS FORM IN FULL OR IT WILL BE RETURNED
Signature
Date
The Privacy Act, 5 U.S.C. § 552a, the Social Security Act, 42 U.S.C. § 405, and N.J.S.A. 34:15-1 et. seq. authorize the Division of
Workers’ Compensation to request that the Petitioner supply the Division with his or her Social Security number for record keeping
purposes and cross-matches with the Social Security Administration, Workforce New Jersey, Temporary Disability Insurance and any
other proper public purpose.
State of New Jersey
FOR STAFF USE ONLY
APPLICATION
Department of Labor and Workforce Development
FOR
Division of Workers’ Compensation
CASE NO: ________________________
PO Box 381
INFORMAL HEARING
Trenton, NJ 08625-0381
VICINAGE: _______________________
WC(CF)-66 (R-2-06)
NEW
ORIGINAL INFORMAL CASE #
AMENDED
SOCIAL SECURITY NUMBER
EMPLOYER
EMPLOYEE
ADDRESS (Including County)
ADDRESS (Including County)
INSURANCE CARRIER
TELEPHONE NUMBER
ADDRESS
DATE OF BIRTH
Name of the Insurance Company can be obtained either from the Employer or by writing to the Compensation Rating and Inspection
Bureau 60 Park Place, Newark, New Jersey 07102 (BE SURE TO INCLUDE A SELF-ADDRESSED STAMPED ENVELOPE)
Date of Accident
Type of Injury
Hearing Requested by:
EMPLOYEE (PETITIONER)
EMPLOYER
INSURANCE CARRIER
PETITIONERS ATTORNEY: If checked, please provide Name and Address of Attorney:
NAME:
ADDRESS:
TELEPHONE NUMBER:
WERE YOU ELIGIBLE FOR MEDICAID BENEFITS AT THE TIME OF THE ACCIDENT?
YES
NO
DID YOU BECOME ELIGIBLE FOR MEDICAID BENEFITS AFTER THE ACCIDENT?
YES
NO
YOU ARE ADVISED THAT MEDICAID PAYMENTS RELATED TO THE ACCIDENT ARE TO BE PAID IN ACCORDANCE
WITH N.J.S.A. 30:14-1, et. seq.
IMPORTANT:
This proceeding will not prevent the Statute of Limitations from expiring. FAILURE TO FILE A
FORMAL PETITION within two years of the date of accident or the last payment and / or authorized
medical treatment by the employer’s insurance carrier can bar any action on a claim filed after that time.
TO INSURE IMMEDIATE PROCESSING,
PLEASE COMPLETE THIS FORM IN FULL OR IT WILL BE RETURNED
Signature
Date
The Privacy Act, 5 U.S.C. § 552a, the Social Security Act, 42 U.S.C. § 405, and N.J.S.A. 34:15-1 et. seq. authorize the Division of
Workers’ Compensation to request that the Petitioner supply the Division with his or her Social Security number for record keeping
purposes and cross-matches with the Social Security Administration, Workforce New Jersey, Temporary Disability Insurance and any
other proper public purpose.