Form WC(DO)-370 "Order Approving Settlement With Dismissal" - New Jersey

What Is Form WC(DO)-370?

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 April 24, 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(DO)-370 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(DO)-370 "Order Approving Settlement With Dismissal" - New Jersey

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State of New Jersey
ORDER APPROVING
CASE NO’S.:
Department of Labor and Workforce Development
SETTLEMENT WITH DISMISSAL
DIVISION OF WORKERS’ COMPENSATION
N.J.S.A. 34:15-20
VICINAGE:
WC(DO)-370 Interactive(r. 4/24/13)
NAME:
FEDERAL EMPLOYER NUMBER
DATE OF BIRTH:
NAME:
YES
NO
MEDICARE ELIGIBLE:
ADDRESS:
ADDRESS:
vs
TELEPHONE NUMBER (AREA CODE):
NAME:
APPEARING:
ADDRESS:
NAME
SELF-INSURED
TPA
ADDRESS:
NAME:
:
ADDRESS
CLAIM NUMBER:
TELEPHONE NUMBER (AREA CODE):
APPEARING:
This is a lump sum settlement between the parties in the amount of $
pursuant to N.J.S.A. 34:15-20 which has the
effect of a dismissal with prejudice, being final as to all rights and benefits of the petitioner and is a complete and absolute surrender and
release of all rights arising out of this/these claim petitions(s). The payment hereunder shall be recognized as a payment of workers’
compensation benefits for insurance rating purposes only.
The parties agree that this settlement [
does (complete page 2) /
does not] contemplate a complete and absolute surrender and
release of any and all rights by the petitioner’s dependents as defined by N.J.S.A. 34:15-13 arising out of this/these claim petition(s).
Order for Child Support Attached
Addendum attached
Further Agreed:
TAX IDENTIFICATION
TOTAL AMT.
PAYABLE BY
PAYABLE BY
ALLOWANCES
REIMBURSE
NUMBER
ALLOWED
PETITIONER
RESPONDENT
MEDICAL FEE ALLOWED: (report and/or testimony)
ATTORNEY(S) FEE:
STENOGRAPHIC SERVICE:
MISCELLANEOUS FEES:
Reason(s) for Section 20 (check all that apply):
Contested issues regarding:
JURISDICTION
LIABILITY
CAUSAL RELATIONSHIP
DEPENDENCY
After considering the circumstances, I find this settlement fair and just.
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 OF WORKERS’ COMPENSATION, PURSUANT TO
RESPONDENT’S ATTORNEY
N.J.S.A. 34:15-121 et. seq.
State of New Jersey
ORDER APPROVING
CASE NO’S.:
Department of Labor and Workforce Development
SETTLEMENT WITH DISMISSAL
DIVISION OF WORKERS’ COMPENSATION
N.J.S.A. 34:15-20
VICINAGE:
WC(DO)-370 Interactive(r. 4/24/13)
NAME:
FEDERAL EMPLOYER NUMBER
DATE OF BIRTH:
NAME:
YES
NO
MEDICARE ELIGIBLE:
ADDRESS:
ADDRESS:
vs
TELEPHONE NUMBER (AREA CODE):
NAME:
APPEARING:
ADDRESS:
NAME
SELF-INSURED
TPA
ADDRESS:
NAME:
:
ADDRESS
CLAIM NUMBER:
TELEPHONE NUMBER (AREA CODE):
APPEARING:
This is a lump sum settlement between the parties in the amount of $
pursuant to N.J.S.A. 34:15-20 which has the
effect of a dismissal with prejudice, being final as to all rights and benefits of the petitioner and is a complete and absolute surrender and
release of all rights arising out of this/these claim petitions(s). The payment hereunder shall be recognized as a payment of workers’
compensation benefits for insurance rating purposes only.
The parties agree that this settlement [
does (complete page 2) /
does not] contemplate a complete and absolute surrender and
release of any and all rights by the petitioner’s dependents as defined by N.J.S.A. 34:15-13 arising out of this/these claim petition(s).
Order for Child Support Attached
Addendum attached
Further Agreed:
TAX IDENTIFICATION
TOTAL AMT.
PAYABLE BY
PAYABLE BY
ALLOWANCES
REIMBURSE
NUMBER
ALLOWED
PETITIONER
RESPONDENT
MEDICAL FEE ALLOWED: (report and/or testimony)
ATTORNEY(S) FEE:
STENOGRAPHIC SERVICE:
MISCELLANEOUS FEES:
Reason(s) for Section 20 (check all that apply):
Contested issues regarding:
JURISDICTION
LIABILITY
CAUSAL RELATIONSHIP
DEPENDENCY
After considering the circumstances, I find this settlement fair and just.
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 OF WORKERS’ COMPENSATION, PURSUANT TO
RESPONDENT’S ATTORNEY
N.J.S.A. 34:15-121 et. seq.
ORDER APPROVING
State of New Jersey
CASE NO’S.:
Department of Labor and Workforce Development
SETTLEMENT WITH DISMISSAL
DIVISION OF WORKERS’ COMPENSATION
N.J.S.A. 34:15-20
WC(DO)-370 Interactive(r. 4/24/13)
VICINAGE:
Page 2
The parties agree that this settlement does contemplate a complete and absolute surrender and release of any and all rights by the
petitioner’s dependents as defined by N.J.S.A. 34:15-13 arising out of this/these claim petitioner(s).
As the spouse or other person who may be defined as a dependent under N.J.S.A. 34:15-13 or the guardian or representative of such a
person, I (we) consent to the entry of this order and recognize that this agreement is a complete and absolute surrender of any rights that I
(we) may have pursuant to N.J.S.A. 34:15-13, should petitioner die as a result of the injuries, conditions, or exposures alleged in this/these
claim petition(s).
Name
Date
Name
Date
On Behalf of
On Behalf of
Name
Date
Name
Date
On Behalf of
On Behalf of
Name
Date
Name
Date
On Behalf of
On Behalf of
I certify that the above is (are) the only individual(s) who is (are) dependent(s) as defined in N.J.S.A. 34:15-13 at the present time.
_________________________________________________________
Petitioner
Date
WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND
After considering the circumstances, I find this settlement fair and just.
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 OF WORKERS’ COMPENSATION, PURSUANT TO
RESPONDENT’S ATTORNEY
N.J.S.A. 34:15-121 et. seq.
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