Form WC-147 "Request for Records Inspection" - New Jersey

What Is Form WC-147?

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 June 27, 2014;
  • 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 fillable version of Form WC-147 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-147 "Request for Records Inspection" - New Jersey

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State of New Jersey
REQUEST FOR RECORDS INSPECTION
Department of Labor and Workforce Development
Division of Workers’ Compensation
P O Box 381
Trenton, New Jersey 08625-0381
WC-147 (R 6-27-2014)
Requestor Information:
1. Requestor Name:
2. Telephone:
3. Company Name:
4. Requestor File No:
6. Account No. (Required, if requestor has an existing account):
□ □ □ □ □ □ □
5. Address:
If you’re a previous requestor, please check if above is a new address
* E-Mail to be used for routine account communications with you
7. E-Mail Address *:
I am seeking records pertaining to the following injured worker and specified cases:
1. Injured Social Security Number (required):
2. Injured Name (required):
3. Identify Cases (one selection must be made):
The following Claim Petition(s):
__________________________________________________________________
All cases for this injured worker
All cases except for the following: __________________________________________________________________
4. Records Requested from each Claim Petition file:
Claim Petition/Answer
Medicals/Exhibits
Closure Documents
Entire Case File
* for Re-Opened case files, only documents dated after the last closure will be provided unless otherwise requested
The following statement must be completed, signed, dated and submitted to the Div. of Workers’ Compensation at the address shown above. Copies of documents
provided through this request shall adhere to the provisions of N.J.S.A. 34:15-128, et seq which limits the inspection and copying of workers’ compensation records.
CERTIFICATION
(Check the appropriate box and complete the required information.)
I, the undersigned, do hereby certify that I am the petitioner, the employer or the insurance carrier as indicated below and that I am requesting the above
record(s) to conduct an investigation in connection with a pending workers’ compensation case, to which I am a party and certify that the record(s) will be
used only for purposes directly related to the case.
_____ Petitioner
_____ Employer
_____Insurance Carrier
I, the undersigned, do hereby certify that I am the authorized agent for the petitioner, the employer or the insurance carrier as set forth in the attached
written agent authorization and that I am requesting the above record(s) to conduct an investigation in connection with a pending workers’ compensation
case, to which I am the authorized agent for a party and certify that the record(s) will be used only for purposes directly related to the case. Agent for:
_____ Petitioner
_____ Employer
_____Insurance Carrier
_____ Written Agent Authorization Attached
I the undersigned do certify that I am a third party directly involved in a workers’ compensation case my status set forth below or the authorized agent of the
third party involved in a workers’ compensation cases whose status is set forth below in the attached written agent authorization and that I am requesting the
above record(s) to conduct an investigation in connection with the case and certify the record(s) will be used only for purposes directly related to the case.
Indicate third party status:
_____ Lienholder _____ PIP Carrier ______________________________ Other (specifically identify)
_____ If Agent, Written Agent Authorization Attached
I, the undersigned do certify that petitioner has authorized the release to me of the above record(s) pursuant to the petitioner signed written authorization
attached for the release of the record(s). I also certify that the release and/or use of the record(s) do not violate N.J.S.A. 34:15-128 (d).
_____ Written Authorization Attached
I certify that the foregoing information made by me is true. I am aware that if any of the foregoing information made by me is willfully false, I am subject to
punishment.
Signature:
____________________________________________________________
Date: _______________________________
Printed Name:
____________________________________________________________
Fees: Copies are certified and billable at a rate of $.05 per page. Billed amounts are due upon presentation.
The Division also reserves the right to deny records requests by any requestor where payment for previous copy work remains unpaid for a period of sixty (60) days
or more following delivery and billing for same.
State of New Jersey
REQUEST FOR RECORDS INSPECTION
Department of Labor and Workforce Development
Division of Workers’ Compensation
P O Box 381
Trenton, New Jersey 08625-0381
WC-147 (R 6-27-2014)
Requestor Information:
1. Requestor Name:
2. Telephone:
3. Company Name:
4. Requestor File No:
6. Account No. (Required, if requestor has an existing account):
□ □ □ □ □ □ □
5. Address:
If you’re a previous requestor, please check if above is a new address
* E-Mail to be used for routine account communications with you
7. E-Mail Address *:
I am seeking records pertaining to the following injured worker and specified cases:
1. Injured Social Security Number (required):
2. Injured Name (required):
3. Identify Cases (one selection must be made):
The following Claim Petition(s):
__________________________________________________________________
All cases for this injured worker
All cases except for the following: __________________________________________________________________
4. Records Requested from each Claim Petition file:
Claim Petition/Answer
Medicals/Exhibits
Closure Documents
Entire Case File
* for Re-Opened case files, only documents dated after the last closure will be provided unless otherwise requested
The following statement must be completed, signed, dated and submitted to the Div. of Workers’ Compensation at the address shown above. Copies of documents
provided through this request shall adhere to the provisions of N.J.S.A. 34:15-128, et seq which limits the inspection and copying of workers’ compensation records.
CERTIFICATION
(Check the appropriate box and complete the required information.)
I, the undersigned, do hereby certify that I am the petitioner, the employer or the insurance carrier as indicated below and that I am requesting the above
record(s) to conduct an investigation in connection with a pending workers’ compensation case, to which I am a party and certify that the record(s) will be
used only for purposes directly related to the case.
_____ Petitioner
_____ Employer
_____Insurance Carrier
I, the undersigned, do hereby certify that I am the authorized agent for the petitioner, the employer or the insurance carrier as set forth in the attached
written agent authorization and that I am requesting the above record(s) to conduct an investigation in connection with a pending workers’ compensation
case, to which I am the authorized agent for a party and certify that the record(s) will be used only for purposes directly related to the case. Agent for:
_____ Petitioner
_____ Employer
_____Insurance Carrier
_____ Written Agent Authorization Attached
I the undersigned do certify that I am a third party directly involved in a workers’ compensation case my status set forth below or the authorized agent of the
third party involved in a workers’ compensation cases whose status is set forth below in the attached written agent authorization and that I am requesting the
above record(s) to conduct an investigation in connection with the case and certify the record(s) will be used only for purposes directly related to the case.
Indicate third party status:
_____ Lienholder _____ PIP Carrier ______________________________ Other (specifically identify)
_____ If Agent, Written Agent Authorization Attached
I, the undersigned do certify that petitioner has authorized the release to me of the above record(s) pursuant to the petitioner signed written authorization
attached for the release of the record(s). I also certify that the release and/or use of the record(s) do not violate N.J.S.A. 34:15-128 (d).
_____ Written Authorization Attached
I certify that the foregoing information made by me is true. I am aware that if any of the foregoing information made by me is willfully false, I am subject to
punishment.
Signature:
____________________________________________________________
Date: _______________________________
Printed Name:
____________________________________________________________
Fees: Copies are certified and billable at a rate of $.05 per page. Billed amounts are due upon presentation.
The Division also reserves the right to deny records requests by any requestor where payment for previous copy work remains unpaid for a period of sixty (60) days
or more following delivery and billing for same.