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

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:
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