Form WC-47 "Decision of Dismissal (Second Injury Fund)" - New Jersey

What Is Form WC-47?

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 January 1, 2017;
  • 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-47 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Labor & Workforce Development.

ADVERTISEMENT
ADVERTISEMENT

Download Form WC-47 "Decision of Dismissal (Second Injury Fund)" - New Jersey

109 times
Rate (4.8 / 5) 5 votes
State of New Jersey
DECISION OF DISMISSAL
Department of Labor and Workforce Development
Case No.:
Division of Workers' Compensation
- Second Injury Fund -
Vicinage:
WC-47 (r. 01/01/17)
EMPLOYER IDN:
SOCIAL SECURITY NUMBER:
NAME:
NAME:
ADDRESS:
ADDRESS:
DATE OF BIRTH:
TELEPHONE NUMBER(AREA CODE):
Ext:
VS
APPEARING FOR PETITIONER:
NAME:
ADDRESS:
Date VP Filed:
Deputy Attorney General Appearing For Second Injury Fund:
At the conclusion of the hearing of this Second Injury Fund Application, I found that:
Petitioner is totally disabled as a consequence of the last compensable injury.
Petitioner is not totally and permanently disabled.
Petitioner has accepted a settlement under the provisions of N.J.S.A. 34:15-20
Petitioner has failed to prosecute this case.
The injuries alleged in this claim petition are not material to the Second Injury Fund Application.
Other:
My findings and conclusions are more fully set forth in my oral opinion and it is ORDERED that this Second Injury fund
Application be dismissed
with /
without prejudice with respect to this claim petition.
WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER
AND ACKNOWLEDGE RECEIPT OF COPY:
JUDGE OF COMPENSATION
PETITIONER'S ATTORNEY
DATE
DATE
PETITIONER
DATE
DEPUTY ATTORNEY GENERAL
DATE
Decision of Dismissal - Second Injury Fund
Page 1 of 1
State of New Jersey
DECISION OF DISMISSAL
Department of Labor and Workforce Development
Case No.:
Division of Workers' Compensation
- Second Injury Fund -
Vicinage:
WC-47 (r. 01/01/17)
EMPLOYER IDN:
SOCIAL SECURITY NUMBER:
NAME:
NAME:
ADDRESS:
ADDRESS:
DATE OF BIRTH:
TELEPHONE NUMBER(AREA CODE):
Ext:
VS
APPEARING FOR PETITIONER:
NAME:
ADDRESS:
Date VP Filed:
Deputy Attorney General Appearing For Second Injury Fund:
At the conclusion of the hearing of this Second Injury Fund Application, I found that:
Petitioner is totally disabled as a consequence of the last compensable injury.
Petitioner is not totally and permanently disabled.
Petitioner has accepted a settlement under the provisions of N.J.S.A. 34:15-20
Petitioner has failed to prosecute this case.
The injuries alleged in this claim petition are not material to the Second Injury Fund Application.
Other:
My findings and conclusions are more fully set forth in my oral opinion and it is ORDERED that this Second Injury fund
Application be dismissed
with /
without prejudice with respect to this claim petition.
WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER
AND ACKNOWLEDGE RECEIPT OF COPY:
JUDGE OF COMPENSATION
PETITIONER'S ATTORNEY
DATE
DATE
PETITIONER
DATE
DEPUTY ATTORNEY GENERAL
DATE
Decision of Dismissal - Second Injury Fund
Page 1 of 1