Form WC-956 "Dependency Claim Petition to Convert Voluntary Tender to Formal Judgment" - New Jersey

Form WC-956 Printable Pdf
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What Is Form WC-956?

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 December 1, 2019;
  • 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-956 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-956 "Dependency Claim Petition to Convert Voluntary Tender to Formal Judgment" - New Jersey

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State of New Jersey
Department of Labor and Workforce Development
DEPENDENCY CLAIM PETITION
Case No.: ______________________________
Division of Workers’ Compensation
To Convert Voluntary Tender to Formal Judgment
PO Box 381
Vicinage:
______________________________
Trenton, New Jersey 08625-0381
Pursuant to N.J.S.A 34:15-95.6
WC-956( r. 12/1/19)
**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 SUPLEMENTAL 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
□
INDIVIDUAL CORPORATE OFFICERS OR OTHERS ARE ALSO NAMED AS
RESPONDENT(S). SEE SUPPLEMENTAL PAGE FOR DETAILS.
SOCIAL SECURITY NUMBER:
DATE OF
□
NAME: (List Petitioner First)
RELATIONSHIP
BIRTH
SSN Not Available
NAME:
1.
ADDRESS:
2.
3.
4.
DATE OF BIRTH:
SEX:
□
See Attached For Additional Dependents (on Page 3)
TO THE DIVISION OF WORKERS’ COMPENSATION - INJURY AND EMPLOYMENT DETAILS:
Date of Accident or Injury:
Date of Death:
If Occupational Disease Give Periods of Exposure:
Occupational Disease:
□
□
YES
NO
Where Injury Occurred (incl. town and county):
How Injury Occurred:
Nature of Injury:
Cause of Death:
Date Injury Reported:
Injury Reported to Whom:
Occupation and Type of Work:
Gross Wages:
Wage Period:
Dependency Rate:
Weekly Benefit Amount paid by
$
$
Insurance Carrier $
If Yes, dependent's monthly Social Security benefit:
Is dependent eligible for Social Security Benefits?:
$
State of New Jersey
Department of Labor and Workforce Development
DEPENDENCY CLAIM PETITION
Case No.: ______________________________
Division of Workers’ Compensation
To Convert Voluntary Tender to Formal Judgment
PO Box 381
Vicinage:
______________________________
Trenton, New Jersey 08625-0381
Pursuant to N.J.S.A 34:15-95.6
WC-956( r. 12/1/19)
**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 SUPLEMENTAL 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
□
INDIVIDUAL CORPORATE OFFICERS OR OTHERS ARE ALSO NAMED AS
RESPONDENT(S). SEE SUPPLEMENTAL PAGE FOR DETAILS.
SOCIAL SECURITY NUMBER:
DATE OF
□
NAME: (List Petitioner First)
RELATIONSHIP
BIRTH
SSN Not Available
NAME:
1.
ADDRESS:
2.
3.
4.
DATE OF BIRTH:
SEX:
□
See Attached For Additional Dependents (on Page 3)
TO THE DIVISION OF WORKERS’ COMPENSATION - INJURY AND EMPLOYMENT DETAILS:
Date of Accident or Injury:
Date of Death:
If Occupational Disease Give Periods of Exposure:
Occupational Disease:
□
□
YES
NO
Where Injury Occurred (incl. town and county):
How Injury Occurred:
Nature of Injury:
Cause of Death:
Date Injury Reported:
Injury Reported to Whom:
Occupation and Type of Work:
Gross Wages:
Wage Period:
Dependency Rate:
Weekly Benefit Amount paid by
$
$
Insurance Carrier $
If Yes, dependent's monthly Social Security benefit:
Is dependent eligible for Social Security Benefits?:
$
□
□
Was the decedent Medicare eligible or a Medicare beneficiary?
YES
NO
□
□
Was the decedent eligible for Medicaid benefits at the time of the work injury?
YES
NO
□
□
Did the decedent 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.
Page 2
State of New Jersey
DEPENDENCY CLAIM PETITION
Department of Labor and Workforce Development
Division of Workers’ Compensation
Case No.: ______________________________
To Convert Voluntary Tender to Formal Judgment
PO Box 381
Trenton, New Jersey 08625-0381
Vicinage:
______________________________
Pursuant to N.J.S.A 34:15-95.6
WC-956 (r. 12/1/19)
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:
ADDITIONAL DEPENDENTS
NAME: (First and Last)
DATE OF BIRTH:
RELATIONSHIP:
New Jersey Department of Labor & Workforce Development New Jersey Legal Forms United States Legal Forms

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Form WC-956 Printable Pdf
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