Form Lc 3437 12 ≡ Fill Out Printable PDF Forms Online

Question	Answer
Form Name	Form Lc 3437 12
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	trial nj state temporary disability forms, new jersey state temp disability application, nj temporary disability forms, temporary disability forms for nj

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Syracuse Benefit Management Services Center

One Park Place, 300 South State Street

P O Box 4925

Syracuse, NY 13221-4925

Telephone 1 800-448-5813

Hartford Fire Insurance Company Hartford Life Insurance Company

PART A

CLAIMANT INFORMATION TO BE COMPLETED BY THE CLAIMANT - PRINT OR TYPE NOTICE OF NEW JERSEY TEMPORARY DISABILITY BENEFITS CLAIM

1. Name (Last, First, Middle) as shown on your Social Security card.

2. Birth Date	3. Social Security Number

Mailing address (Street, City or Town, State, Zip Code)

5. Home Telephone Number

6. Married (Check one.)

Male

(

)

Yes

Female

Employer (Name, Address and Telephone number)

Occupation

10. Are you a citizen of the United. States?

Yes

If "No," complete block

11. Alien Reg. No.

12. Work Authorization

#11 & #12, and give country of origin.

From

13.

The last day you worked before your disability began

Month

Day

Year

14.

The first day you were unable to work due to present disability

(Include Saturday, Sunday, or Holiday)

15.

If now recovered, date of your recovery or return to work

......................................................................

16.

Date(s) of emergency room care

or hospitalization From:

To:

Month/Day/Year

17. Describe your disability:

If due to accident, give date:

Month/Day/Year

18. Was this disability caused by your job?

Yes

No If "Yes," describe:

19. Name and address of physician or hospital treating you for this disability:

Employment information Other employers you have worked for during the past 18 months. Include full-time and part-time employment. If you had more than 3 employers, list on a separate sheet and attach to this form.

20a. Name and Address:

(Street)

(City)

(State)

(Zip)

Period of Employment:

FromTo

Month/Day/YearMonth/Day/Year

Telephone No.

( )

Work Location

Occupation:

Union Name:

Division:

20b. Name and Address:

Period of Employment:

Telephone No.

(

)

From

Work Location

Month/Day/Year

(Street)

(City)

(State)

(Zip)

Occupation:

Union Name:

Division:

21. Other Benefits: (You must answer each question listed below for the period of disability covered by this claim.)

a. Have you been working (including self-employment)?

Yes

b. Have you been receiving remuneration, i.e., wages, salary or vacation pay?

Yes

22. Since your last day of work have you received, claimed or applied for

d. Any other disability benefits provided by

a. Social Security benefits?

Yes

your employer or Union?

Yes

e. Workers' Compensation benefits?

b. Social Security Retirement benefits?

Yes

c. Pension benefits from your most recent employer?

Yes

f. Unemployment insurance benefits?

Yes

23. I request voluntary Federal Tax Withholding

No If "Yes," indicate the amount to be withheld from weekly benefits. $

Yes

($20.00 minimum withholding per week)

24.CERTIFICATION AND SIGNATURE

I was unable to work during the period for which benefits are claimed and hereby certify that I have read and understand my benefit right. Also, I certify that the foregoing statements made by me on this form are true. I am aware that if any of the foregoing statements made by me are willfully false, I may be subject to penalties, which include criminal prosecution. You are hereby authorized to obtain any medical and employment information that is necessary to determine the eligibility of this claim.

Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Any person who includes any false or misleading information on an application for insurance policy is subject to criminal and civil penalties.

SIGN HERE ☞	(Claimant's Signature)	(Date)

LC-3437-12 (Rev 02/02) Printed in U.S.A.

(Tel. No.)

PART B

MEDICAL CERTIFICATE (To be completed by your doctor)

............................................................................................................1. Patient was first treated by me on						Month	Day	Year
	Patient was last treated by me on					Month	Day	Year
2 .	Is the patient unable to perform his/her regular work?		Yes		No
2 .	Is the patient unable to perform his/her regular work?		Yes		No
	..........If "Yes," please enter the date the disability began	...................		..............................................................		Month	Day	Year
						Month	Day	Year
3.	Estimate recovery (give the approximate date claimant will be able to return to work)				.....................................................................	Month	Day	Year
						Month	Day	Year
4.	If now recovered, on what date was the claimant first able to work?					Month	Day	Year
						Month	Day	Year

5.Diagnosis (nature and cause of this disability which prevents claimant from working):

ICD Code:

Clinical data and test to support diagnosis:

6.(a) If pregnant, provide estimated date of delivery.............................................................................................

Complications, if any:

Month

Day

Year

(b) If pregnancy has terminated, enter the date

and the reason:

Vaginal

C-Section

Miscarriage

Others

Month

Day

Year

7. Date(s) of emergency room care or hospitalization:

From:

To:

Month

Day

Year

Month

Day

Year

Type of Surgery:

CPT Code:

Date of Surgery:

Date Surgery Contemplated:

In your opinion, was this disability

Due to an accident at work?

Not related to his/her work?

Due to a condition which developed because of the nature of the work?

	(Print Doctor's Name and Degree)			(Doctor's Signature)

Street Address	(City)	(State and Zip)	(Specialty)	(Certificate License No. and State)
(Telephone Number) (	)	(Date Signed)

PART C

TO BE COMPLETED BY YOUR EMPLOYER

1. EMPLOYEE NAME:	Social Security Number	Policy /Plan Number

2. EMPLOYEE STATUS:			Full Time
EMPLOYMENT DATE:


Part Time	Intermittent	Seasonal	Other Explain:
EFFECTIVE DATE OF INSURANCE:
EFFECTIVE DATE OF INSURANCE:

3. DATA REGARDING LAST DAY WORKED

(a) Claimant's last day worked before this disability

Month

Day

Year

(b) Exact reason for separation from work on the date listed in

item (a) include labor dispute):

(c)

Is lack of work

Temporary?

Permanent?

(d)

Has claimant returned to work?

Yes

If "Yes," give date:

If the work was

intermittant, list

dates:

4.CONTINUED PAY

(a)Have you paid the claimant since the last day of work? Yes No

(b)These monies represent pay

	From: Month		Day	Year	To: Month	Day	Year

(c) Total gross paid for the above period: $
(c) Total gross paid for the above period: $
Amount per week:$		(If amount varies, attach list of dates and amounts.)
Amount per week:$		(If amount varies, attach list of dates and amounts.)

(d)Circle the number that best describes the monies paid in item (c)

1.Regular weekly wage and/or sick pay

2.Regular vacation (if designated for a specific time period)

3.Pension

4.Difference between regular weekly wage and disability benefits to be received

5.Supplemental benefits or gratuities

6.Payments required to be made under the State mandated temporary disability

benefit plan pursuant to the New Jersey Disability law.

Note: Items (d) 1, 2, and 3 may reduce benefits to the claimant.

(e) Are you requesting to be compensated for wage continuance? Yes No

5.WORKERS' COMPENSATION LIABILITY

(a)Did the claimant's disability happen in connection with his/her work or while on

premises, or was the disability due in any way to his/her occupation Yes No

(b)If "Yes," have you filed, or do you intend to file a Workers' Compensation claim

on behalf of this claimant? Yes No

(c)If "Yes," give name address and telephone number of your Workers' Compensation

carrier. (Name)

(Address)

6.BASE WEEKS AND BASE GROSS WAGES In how many calendar weeks did this claimant earn $144* or more with you

in NEW JERSEY EMPLOYMENT during his/her base year, which is the 52 weeks immediately preceding the week in which

the disability began? *1999 BASE WEEK AMT $144. Changes

Jan 1 each year.

(a)Total number of Base Weeks

(b)Total Gross Wages in Base Year

(Include all wages earned by the claimant.)

7.REGULAR WEEKLY WAGE $

8.WEEKLY WAGES Indicate below: Dates and claimant's Gross Earnings in NJ employment during the eight calendar weeks prior to the week in which the disability began.

Description of Calendar Week			Calendar Week		Gross Paid
Description of Calendar Week			Ending Date		Gross Paid
Week Before Disability					$
2nd Week Before Disability					$
3rd Week Before Disability					$
4th Week Before Disability					$
5th Week Before Disability					$
6th Week Before Disability					$
7th Week Before Disability					$
8th Week Before Disability					$

Total Gross Wages For the Above Eight Weeks				$
Is employee enrolled in a Hartford LTD Plan?
	Yes	No If "Yes," effective date:

Based on the employer/employee premium contributions made over the last 3 years, what percentage of the Weekly Disability

% LTD

benefit is considered taxable? (See Section 7 of IRS Publication 15-A for information on determining the taxable percentage.) If blank, we will assume the benefit is 100% taxable.

Firm Name

I certify that the above information is

Signed

Address

Official Title

City, State and Zip Code

Telephone Number (

)

Date

LC-3437-12 (Rev. 02/02)

Form Lc 3437 12 – Fill Out and Use

Nj Lc 3437 Disability Details

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Form Lc 3437 12 – Fill Out and Use

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