Form Lc 3437 12 is a tax form used to report the sale or exchange of property. The form must be filed by the person who engaged in the transaction, and it must be submitted to the Internal Revenue Service (IRS). The form is used to report a variety of transactions, including sales of stocks, mutual funds, real estate, and personal property. It's important to understand how this form works so you can accurately report any transactions you make. Let's take a closer look at Form Lc 3437 12.
You will discover information about the type of form you want to prepare in the table. It can show you how much time it will need to finish form lc 3437 12, what fields you need to fill in, and so on.
Question | Answer |
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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 |
Syracuse Benefit Management Services Center
One Park Place, 300 South State Street
P O Box 4925
Syracuse, NY
Telephone 1
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 |
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4. |
Mailing address (Street, City or Town, State, Zip Code) |
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5. Home Telephone Number |
6. Married (Check one.) |
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Male |
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Yes |
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No |
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Female |
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8. |
Employer (Name, Address and Telephone number) |
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9. |
Occupation |
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10. Are you a citizen of the United. States? |
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Yes |
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No |
If "No," complete block |
11. Alien Reg. No. |
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12. Work Authorization |
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#11 & #12, and give country of origin. |
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13. |
The last day you worked before your disability began |
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Year |
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14. |
The first day you were unable to work due to present disability |
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(Include Saturday, Sunday, or Holiday) |
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15. |
If now recovered, date of your recovery or return to work |
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16. |
Date(s) of emergency room care |
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or hospitalization From: |
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To: |
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Month/Day/Year |
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Month/Day/Year |
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Month/Day/Year |
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17. Describe your disability:
If due to accident, give date:
Month/Day/Year
18. Was this disability caused by your job? |
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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
20a. Name and Address:
(Street) |
(City) |
(State) |
(Zip) |
Period of Employment:
FromTo
Month/Day/YearMonth/Day/Year
Telephone No.
( )
Work Location
Occupation: |
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Union Name: |
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Division: |
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20b. Name and Address: |
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Period of Employment: |
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Telephone No. |
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From |
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Work Location |
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Month/Day/Year |
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Month/Day/Year |
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(Street) |
(City) |
(State) |
(Zip) |
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Occupation: |
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Union Name: |
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Division: |
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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 |
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Yes |
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No |
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b. Have you been receiving remuneration, i.e., wages, salary or vacation pay? |
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Yes |
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No |
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22. Since your last day of work have you received, claimed or applied for |
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d. Any other disability benefits provided by |
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a. Social Security benefits? |
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Yes |
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No |
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your employer or Union? |
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Yes |
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No |
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e. Workers' Compensation benefits? |
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b. Social Security Retirement benefits? |
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Yes |
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No |
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Yes |
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No |
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c. Pension benefits from your most recent employer? |
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Yes |
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No |
f. Unemployment insurance benefits? |
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Yes |
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No |
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23. I request voluntary Federal Tax Withholding |
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No If "Yes," indicate the amount to be withheld from weekly benefits. $ |
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Yes |
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($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) |
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PART B
MEDICAL CERTIFICATE (To be completed by your doctor)
............................................................................................................1. Patient was first treated by me on |
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Patient was last treated by me on |
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2 . |
Is the patient unable to perform his/her regular work? |
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Yes |
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No |
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..........If "Yes," please enter the date the disability began |
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3. |
Estimate recovery (give the approximate date claimant will be able to return to work) |
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4. |
If now recovered, on what date was the claimant first able to work? |
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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.............................................................................................
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Complications, if any: |
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(b) If pregnancy has terminated, enter the date |
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and the reason: |
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Vaginal |
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Miscarriage |
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Others |
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7. Date(s) of emergency room care or hospitalization: |
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From: |
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To: |
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8. |
Type of Surgery: |
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CPT Code: |
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Date of Surgery: |
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Date Surgery Contemplated: |
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9. |
In your opinion, was this disability |
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Due to an accident at work? |
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Not related to his/her work? |
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Due to a condition which developed because of the nature of the work?
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(Print Doctor's Name and Degree) |
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(Doctor's Signature) |
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Street Address |
(City) |
(State and Zip) |
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(Specialty) |
(Certificate License No. and State) |
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(Telephone Number) ( |
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(Date Signed) |
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PART C
TO BE COMPLETED BY YOUR EMPLOYER
1. EMPLOYEE NAME: |
Social Security Number |
Policy /Plan Number |
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2. EMPLOYEE STATUS: |
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Full Time |
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EMPLOYMENT DATE: |
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Part Time |
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Intermittent |
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Seasonal |
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Other Explain: |
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EFFECTIVE DATE OF INSURANCE: |
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3. DATA REGARDING LAST DAY WORKED |
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(a) Claimant's last day worked before this disability |
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(b) Exact reason for separation from work on the date listed in |
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item (a) include labor dispute): |
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(c) |
Is lack of work |
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Temporary? |
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Permanent? |
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(d) |
Has claimant returned to work? |
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Yes |
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No |
If "Yes," give date: |
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If the work was |
intermittant, list |
dates: |
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4.CONTINUED PAY
(a)Have you paid the claimant since the last day of work? Yes No
(b)These monies represent pay
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(c) Total gross paid for the above period: $ |
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Amount per week:$ |
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(If amount varies, attach list of dates and amounts.) |
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(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.
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Description of Calendar Week |
Calendar Week |
Gross Paid |
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Ending Date |
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Week Before Disability |
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$ |
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2nd Week Before Disability |
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$ |
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3rd Week Before Disability |
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$ |
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4th Week Before Disability |
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$ |
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5th Week Before Disability |
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$ |
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6th Week Before Disability |
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$ |
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7th Week Before Disability |
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$ |
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8th Week Before Disability |
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$ |
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Total Gross Wages For the Above Eight Weeks |
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Is employee enrolled in a Hartford LTD Plan? |
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Yes |
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No If "Yes," effective date: |
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Based on the employer/employee premium contributions made over the last 3 years, what percentage of the Weekly Disability |
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% LTD |
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% |
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benefit is considered taxable? (See Section 7 of IRS Publication |
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Firm Name |
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I certify that the above information is |
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Signed |
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Address |
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Official Title |
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City, State and Zip Code |
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Telephone Number ( |
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Date |
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