Form WC-365 "Employee Claim Petition" - New Jersey

What Is Form WC-365?

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 August 26, 2015;
  • 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-365 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-365 "Employee Claim Petition" - New Jersey

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State of New Jersey
EMPLOYEE CLAIM PETITION
Department of Labor and Workforce Development
Case No.: ______________________________
Division of Workers’ Compensation
PO Box 381
Vicinage:
______________________________
Trenton, New Jersey 08625-0381
NEW FILING
AMENDED FILING
WC-365 8/26/2015
**please enter above only if filing an Amended Claim**
SOCIAL SECURITY NUMBER:
TAX IDENTIFICATION NUMBER:
SSN Not Available
NAME:
NAME:
ADDRESS:
ADDRESS:
DATE OF BIRTH:
SEX:
TELEPHONE NUMBER:
FAX NUMBER:
A guardian or other representative is filing on behalf of the petitioner. See
Supplemental Page for details.
vs
NAME:
NAME:
IF EMPLOYER IS KNOWN BY DIFFERENT NAME, PLEASE INDICATE HERE:
ADDRESS:
ADDRESS:
CARRIER CLAIM NUMBER:
INDICATE THE STATUS OF THE EMPLOYER:
PERIOD OF COVERAGE:
FROM:
TO:
INSURED
UNINSURED
SELF-INSURED (PRIVATE)
SELF-INSURED (GOVT. AGENCY)
See Supplemental Page for additional carriers
If uninsured, individual corporate officers, or others, are also named as
respondent(s). See Supplemental Page for details.
TO THE DIVISION OF WORKERS’ COMPENSATION - INJURY AND EMPLOYMENT DETAILS:
Date of Accident or Last Exposure:
Occupational Disease:
If Occupational Disease Give Periods of Exposure:
YES
NO
Where Injury Occurred (incl. town and county):
How Injury Occurred:
DESCRIBE EXTENT AND CHARACTER OF INJURY: If there has been amputation or disability to any member or impairment of any physical function, explain fully:
Date Stopped Work:
Date Returned to Work:
Date Injury Reported:
Injury Reported To Whom:
Occupation and Type of Work:
Gross Wages
Wage Period:
Rate of Temp. Compensation:
Weeks of Temp. Disability
Temporary Disability Paid:
Permanent Disability Paid:
$
$
paid:
$
$
:
YES
NO
Employer Furnished Medical Aid
Demand is hereby made for answers to standard occupational disease interrogatories. [N.J.A.C. 12:235-3.8(f)]
Demand is hereby made for all records of medical treatment, examinations and diagnostic studies. [N.J.A.C. 12:235-3.8 (c)]
Are you Medicare eligible or a Medicare beneficiary?
YES
NO
Were you eligible for Medicaid benefits at the time of the work injury?
YES
NO
Did you become eligible for Medicaid benefits after the work injury?
YES
NO
What other facts are there that you believe important:
State of New Jersey
EMPLOYEE CLAIM PETITION
Department of Labor and Workforce Development
Case No.: ______________________________
Division of Workers’ Compensation
PO Box 381
Vicinage:
______________________________
Trenton, New Jersey 08625-0381
NEW FILING
AMENDED FILING
WC-365 8/26/2015
**please enter above only if filing an Amended Claim**
SOCIAL SECURITY NUMBER:
TAX IDENTIFICATION NUMBER:
SSN Not Available
NAME:
NAME:
ADDRESS:
ADDRESS:
DATE OF BIRTH:
SEX:
TELEPHONE NUMBER:
FAX NUMBER:
A guardian or other representative is filing on behalf of the petitioner. See
Supplemental Page for details.
vs
NAME:
NAME:
IF EMPLOYER IS KNOWN BY DIFFERENT NAME, PLEASE INDICATE HERE:
ADDRESS:
ADDRESS:
CARRIER CLAIM NUMBER:
INDICATE THE STATUS OF THE EMPLOYER:
PERIOD OF COVERAGE:
FROM:
TO:
INSURED
UNINSURED
SELF-INSURED (PRIVATE)
SELF-INSURED (GOVT. AGENCY)
See Supplemental Page for additional carriers
If uninsured, individual corporate officers, or others, are also named as
respondent(s). See Supplemental Page for details.
TO THE DIVISION OF WORKERS’ COMPENSATION - INJURY AND EMPLOYMENT DETAILS:
Date of Accident or Last Exposure:
Occupational Disease:
If Occupational Disease Give Periods of Exposure:
YES
NO
Where Injury Occurred (incl. town and county):
How Injury Occurred:
DESCRIBE EXTENT AND CHARACTER OF INJURY: If there has been amputation or disability to any member or impairment of any physical function, explain fully:
Date Stopped Work:
Date Returned to Work:
Date Injury Reported:
Injury Reported To Whom:
Occupation and Type of Work:
Gross Wages
Wage Period:
Rate of Temp. Compensation:
Weeks of Temp. Disability
Temporary Disability Paid:
Permanent Disability Paid:
$
$
paid:
$
$
:
YES
NO
Employer Furnished Medical Aid
Demand is hereby made for answers to standard occupational disease interrogatories. [N.J.A.C. 12:235-3.8(f)]
Demand is hereby made for all records of medical treatment, examinations and diagnostic studies. [N.J.A.C. 12:235-3.8 (c)]
Are you Medicare eligible or a Medicare beneficiary?
YES
NO
Were you eligible for Medicaid benefits at the time of the work injury?
YES
NO
Did you become eligible for Medicaid benefits after the work injury?
YES
NO
What other facts are there that you believe important:
Summary of Changes (Complete only if filing an Amended pleading):
Petitioner therefore requests that the Division of Workers’ Compensation determine the amount of compensation due Petitioner
from said Respondent, pursuant to R.S. 34:15-7 et seq., and that Petitioner may be awarded Petitioner’s costs in this proceeding, and such
other or further relief as may be proper.
___________________________________________________
Petitioner
STATE OF NEW JERSEY
COUNTY OF ________________________
Subscribed and sworn or affirmed
to before me this _______ day of __________________ , 20_____
____________________________________________
Please be advised that information collected from the filing of this claim petition may be used by the Division of Workers’
Compensation for record keeping, record access/distribution, and case scheduling purposes. Petitions filed with the Division are public
documents and may be inspected and copied except where prohibited by Section 34:15-128 of the Workers’ Compensation Statute.
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
Department of Labor and Workforce Development
EMPLOYEE CLAIM PETITION
Division of Workers’ Compensation
Case No.: ______________________________
PO Box 381
SUPPLEMENTAL PAGE
Trenton, New Jersey 08625-0381
Vicinage:
______________________________
WC-365.1 5/7/2015
GUARDIAN OR REPRESENTATIVE
NAME:
ADDRESS:
RELATIONSHIP TO PETITIONER:
ADDITIONAL CARRIERS
NAME:
NAME:
ADDRESS:
ADDRESS:
CARRIER CLAIM NUMBER:
CARRIER CLAIM NUMBER:
PERIOD OF COVERAGE:
PERIOD OF COVERAGE:
FROM:
TO:
FROM:
TO:
NAME:
NAME:
ADDRESS:
ADDRESS:
CARRIER CLAIM NUMBER:
CARRIER CLAIM NUMBER:
PERIOD OF COVERAGE:
PERIOD OF COVERAGE:
FROM:
TO:
FROM:
TO:
INDIVIDUAL CORPORATE OFFICERS/PARTNERS/LLC MEMBERS
NAME:
NAME:
ADDRESS:
ADDRESS:
NAME:
NAME:
ADDRESS:
ADDRESS:
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