Form WC-377I "Addendum to Order for Total Disability" - New Jersey

What Is Form WC-377I?

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 March 19, 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-377I 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-377I "Addendum to Order for Total Disability" - New Jersey

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ADDENDUM TO
State of New Jersey
CASE NO’S.:
Department of Labor and Workforce Development
ORDER FOR
DIVISION OF WORKERS’ COMPENSATION
TOTAL DISABILITY
WC-377i (r.3/19/13)
VICINAGE:
Case Name:
Petitioner’s Social Security Number:
Petitioner is in receipt of a government ordinary disability retirement pension. The date of retirement was
. The
initial retirement benefit was $
per month. The pension portion of the retirement benefit was $
per
month. The annuity portion of the retirement benefit was $
per month. The respondent and/or the Second Injury Fund
is/are entitled to an offset for this benefit. Based upon the last compensable injury and the reasons for the ordinary disability retirement,
the offset shall be
% of the pension portion of the retirement benefit, or $
per week resulting in a weekly rate of
$
.
Other:
DATE
JUDGE OF COMPENSATION
WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS
ORDER AND ACKNOWLEDGE RECEIPT OF COPY:
PETITIONER’S ATTORNEY
RESPONDENT’S ATTORNEY
PETITIONER (where applicable)
DEPUTY ATTORNEY GENERAL
ADDENDUM TO
State of New Jersey
CASE NO’S.:
Department of Labor and Workforce Development
ORDER FOR
DIVISION OF WORKERS’ COMPENSATION
TOTAL DISABILITY
WC-377i (r.3/19/13)
VICINAGE:
Case Name:
Petitioner’s Social Security Number:
Petitioner is in receipt of a government ordinary disability retirement pension. The date of retirement was
. The
initial retirement benefit was $
per month. The pension portion of the retirement benefit was $
per
month. The annuity portion of the retirement benefit was $
per month. The respondent and/or the Second Injury Fund
is/are entitled to an offset for this benefit. Based upon the last compensable injury and the reasons for the ordinary disability retirement,
the offset shall be
% of the pension portion of the retirement benefit, or $
per week resulting in a weekly rate of
$
.
Other:
DATE
JUDGE OF COMPENSATION
WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS
ORDER AND ACKNOWLEDGE RECEIPT OF COPY:
PETITIONER’S ATTORNEY
RESPONDENT’S ATTORNEY
PETITIONER (where applicable)
DEPUTY ATTORNEY GENERAL