Form WC-100 "Order for Dismissal" - New Jersey

What Is Form WC-100?

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 July 1, 2013;
  • 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-100 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-100 "Order for Dismissal" - New Jersey

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State of New Jersey
CASE NO’S.:
Department of Labor and Workforce Development
ORDER FOR DISMISSAL
DIVISION OF WORKERS’ COMPENSATION
WC-100-Dismissal Interactive (r. 7/1/2013)
VICINAGE:
NAME:
FEDERAL EMPLOYER NUMBER:
DATE OF BIRTH:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE NUMBER (AREA CODE):
vs
NAME:
APPEARING:
ADDRESS:
NAME
SELF-INSURED
TPA
ADDRESS:
NAME:
:
ADDRESS
CLAIM NUMBER:
TELEPHONE NUMBER (AREA CODE):
APPEARING:
,
THIS MATTER HAVING COME BEFORE THE COURT ON THIS
DAY OF
ORDER FOR DISMISSAL WITHOUT PREJUDICE
Lack of Prosecution pursuant to NJSA 34:15-54, subject to the right to apply to the Division of Workers'
Compensation to have the petition reinstated for good cause, within one year from the date of this dismissal.
Other:
ORDER FOR DISMISSAL WITH PREJUDICE
Failure to Sustain Burden of Proof
Other:
TAX IDENTIFICATION
TOTAL AMT.
PAYABLE BY
PAYABLE BY
ALLOWANCES
REIMBURSE
NUMBER
ALLOWED
PETITIONER
RESPONDENT
STENOGRAPHIC SERVICE:
WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND
ACKNOWLEDGE RECEIPT OF COPY:
PETITIONER’S ATTORNEY
JUDGE OF COMPENSATION
DATE
PETITIONER (where applicable)
JUDGE’S NAME
THE ORIGINAL OF THIS DOCUMENT, SIGNED BY THE JUDGE OF
COMPENSATION, WILL BE MAINTAINED ON FILE IN THE DIVISION
RESPONDENT’S ATTORNEY
OF WORKERS’ COMPENSATION, PURSUANT TO
N.J.S.A. 34:15-121 et seq.
State of New Jersey
CASE NO’S.:
Department of Labor and Workforce Development
ORDER FOR DISMISSAL
DIVISION OF WORKERS’ COMPENSATION
WC-100-Dismissal Interactive (r. 7/1/2013)
VICINAGE:
NAME:
FEDERAL EMPLOYER NUMBER:
DATE OF BIRTH:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE NUMBER (AREA CODE):
vs
NAME:
APPEARING:
ADDRESS:
NAME
SELF-INSURED
TPA
ADDRESS:
NAME:
:
ADDRESS
CLAIM NUMBER:
TELEPHONE NUMBER (AREA CODE):
APPEARING:
,
THIS MATTER HAVING COME BEFORE THE COURT ON THIS
DAY OF
ORDER FOR DISMISSAL WITHOUT PREJUDICE
Lack of Prosecution pursuant to NJSA 34:15-54, subject to the right to apply to the Division of Workers'
Compensation to have the petition reinstated for good cause, within one year from the date of this dismissal.
Other:
ORDER FOR DISMISSAL WITH PREJUDICE
Failure to Sustain Burden of Proof
Other:
TAX IDENTIFICATION
TOTAL AMT.
PAYABLE BY
PAYABLE BY
ALLOWANCES
REIMBURSE
NUMBER
ALLOWED
PETITIONER
RESPONDENT
STENOGRAPHIC SERVICE:
WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND
ACKNOWLEDGE RECEIPT OF COPY:
PETITIONER’S ATTORNEY
JUDGE OF COMPENSATION
DATE
PETITIONER (where applicable)
JUDGE’S NAME
THE ORIGINAL OF THIS DOCUMENT, SIGNED BY THE JUDGE OF
COMPENSATION, WILL BE MAINTAINED ON FILE IN THE DIVISION
RESPONDENT’S ATTORNEY
OF WORKERS’ COMPENSATION, PURSUANT TO
N.J.S.A. 34:15-121 et seq.