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STATE OF NEW JERSEY – DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

DIVISION OF TEMPORARY DISABILITY INSURANCE

PART A

INFORMATION TO BE COMPLETED BY THE CLAIMANT – Print or Type WDS-1(R-2-08)

1. Name: Last	First	Middle	2. Birth Date
			\|	\|

4. Home Address – required (Street, Apt #, City, State, Zip Code)

3.Social Security Number

| |

5. County

6. Mailing Address – if different (Street, Apt #, City State, Zip Code)							7.Male		8. Occupation
							Female

9. Are you a citizen of the United States? Yes		No		10. Alien Reg. No.		11. Work Authorization
If NO, answer #10 & 11 and give country of origin: ______________						From ___________ To ___________
						From ___________ To ___________
12a. What was the last day that you actually worked before your disability began?						Month		Day		Year
12b. Reason for separation:	Illness/Accident/Maternity		Terminated		Quit
13. What was the first day you were unable to work due to present disability:
(Include Saturday, Sunday, or Holiday) Do not list future dates

14.If you have recovered or returned to work from this disability, list date:

(Do not use dates in the future)

15. Date(s) of emergency room care:__________________ or hospitalization: From ___________________ To ___________________

Month/Day/YearMonth/Day/Year Month/Day/Year

16. Describe your disability (How, when, where it happened) _________________________________________________________

________________________________________________________________________________________________________________________________________

17. Was this injury/illness caused by your job?	Yes	or	No
If Yes, date of work related injury/illness:_________________
Was your employer notified that your injury was caused by your job?			Yes

(This question must be answered.)

or No

18. Identify the physician or hospital treating you for this disability: Name: ________________________________________________

Address: ____________________________________________________________ Telephone: (_____)_________________________

Employment Information – Beginning with your last employer, list all employment (both full and part-time) in the past 18
months. If you had more than 2 employers, list the remaining employers on the reverse side of this form in the space provided.
19a. Name and address of your most recent employer:			Period of employment: From _______________ To_____________
__________________________________________________			Period of employment: From _______________ To_____________
__________________________________________________			month/day/year	month/day/year
			month/day/year	month/day/year
__________________________________________________			Work
__________________________________________________			Telephone: ____________________ Location _________________
(Street)	(City)	(State) (Zip)	City	State
			City	State

Occupation: ________________________________ Full time

Part time

Union _____________ Division___________________

Check the days of the week you normally work. SUN

MON

TUE

WED

THUR

FRI

SAT

19b. Name and address:

__________________________________________________

(Street)

(City)

(State)

(Zip)

Period of employment: From _______________ To____________

month/day/year month/day/year

Work

Telephone: ____________________ Location _________________

City State

Occupation: ________________________________ Full time

Part time

Union _____________Division___________________

Check the days of the week you normally work. SUN

MON

TUE

WED

THUR

FRI

SAT

20.Other Benefits – You Must Answer Each Question Listed Below For the Period of Disability Covered By This Claim:

a. Have you worked after your disability began? (Including self-employment)	Yes	No
b. Have you been receiving sick or vacation pay?	Yes	No
c. Have you been involved in a labor dispute?	Yes	No

21. Since your last day of work have you received, claimed or applied for: d. Any other disability benefits provided by your

a. Federal Social Security Disability Benefits?	Yes	No	employer or union?	Yes	No
b. Pension benefits from your most recent employer? Yes		No	e. Unemployment Insurance Benefits? Yes		No
c. Temporary Disability Benefits from another State? Yes		No

BE SURE TO COMPLETE AND SIGN PART A1

STDNJ0109 250	1 OF 4

WDS-1 (R-2-08)

Claimant’s Name:_________________________________________

Claimant’s Telephone No: (_____)___________________________

Social Security Number

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	PART A1	CLAIMANT’S AUTHORIZATION AND CERTIFICATION STATEMENTS
	PART A1	MUST BE COMPLETED AND SIGNED BY THE CLAIMANT
		MUST BE COMPLETED AND SIGNED BY THE CLAIMANT

1.Please designate a representative to obtain claim information for you if you cannot call this Agency yourself. The Law only permits claim information to be given to you or your representative.

Representative Name: ___________________________________________________Birth Date:_____________________________

Phone (______ )____________________________________

2.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 rights and responsibilities. I am aware that if any of the foregoing statements made by me are known to be false, or I knowingly fail to disclose a material fact, I may be subject to penalties, which may include criminal prosecution. You are hereby authorized to verify my Social Security Account Number, and obtain any medical, employment and Social Security benefit entitlement information that is necessary to determine my eligibility for benefits.

Sign Here ________________________________________________________________Date______________________________

Witness signature if claimant writes an “X” _______________________________________________________________________

Phone No. (_____)_____________________________ E-Mail Address _______________________________________________

Note: The NJ Temporary Disability Benefits Program is not a “covered entity” under the Federal Health Information Portability & Accountability Act (HIPAA). All medical records of the Division, except to the extent necessary for the proper administration of the Temporary Disability Benefits Law are confidential & are not open to public inspection. The Division protects all records that may reveal the identity of the claimant, or the nature or cause of the disability and the records may only be used in proceedings arising under the Law.

USE THIS SPACE TO LIST ADDITIONAL EMPLOYERS FOR QUESTION 19.

Name and address:

__________________________________________________

(Street)

(City)

(State)

(Zip)

Period of employment: From _______________ To____________

month/day/year month/day/year

Work

Telephone: ______________ Location ______________________

City State

Occupation: ________________________________ Full time

Part time

Union _____________Division___________________

Check the days of the week you normally work. SUN

MON

TUE

WED

THUR

FRI

SAT

Name and address:

__________________________________________________

(Street)

(City)

(State)

(Zip)

Period of employment: From _______________ To____________

month/day/year month/day/year

Work

Telephone: ______________ Location ______________________

City State

Occupation: ________________________________ Full time

Part time

Union _____________Division___________________

Check the days of the week you normally work. SUN

MON

TUE

WED

THUR

FRI

SAT

USE THIS SPACE TO PROVIDE ANY ADDITIONAL INFORMATION FOR QUESTIONS ON PART A

_____________________________________________________________________________________________________________

If more space is needed, attach an additional sheet of paper. Be sure your Social Security Number appears on all pages.

2 OF 4

WDS-1(R-2-08)

Claimant’s Name: ________________________________________________

Claimant’s Address:_______________________________________________

Claimant’s Telephone No:(_______)__________________________________

Social Security Number

| |

PART B

MEDICAL CERTIFICATE

(TO BE COMPLETED BY YOUR DOCTOR AFTER YOU BECOME DISABLED)

1a. Patient has been under my care for this period of disability: FROM ____________________ TO __________________________

(Month/Day/Year) (Month/Day/Year)

b.Frequency of treatment: ___________________________________

c.	Patient was last treated by me on:	____________\|___________\|_________
		Month	Day	Year
2.	Enter the date the patient was unable to perform his/her regular work due to this disability: _______\|___________\|_________
		Month	Day	Year
3.	Estimated Recovery: (Give the approximate date patient will be able to return to work.)	____________\|___________\|_________
		Month	Day	Year
4.	If now recovered, on what date was the patient first able to work?	____________\|___________\|_________
		Month	Day	Year

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

_____________________________________________________________________________ ICD Code: _____________________

Clinical data and tests to support diagnosis:__________________________________________________________________________

6a. If pregnancy, provide estimated date of delivery:	____________\|___________\|_________
	Month	Day	Year

b.Complications, if any.____________________________________________________

c. If pregnancy terminated, enter the date:				____________\|___________\|_________
				Month	Day	Year
And identify the reason:	Birth	C-Section	Miscarriage	Abortion

7a. Date(s) of emergency room care or hospitalization: FROM _________________________ TO _________________________

b.Name and address of any specialist treating patient: ____________________________________________________________

8.Type of surgery: _______________________ Date of Surgery __________________ Anticipated Surgery Date _________________

	Is surgery for cosmetic purposes only?			Yes	No
9.	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.

10.	Was this patient referred to you?		Yes	No	If yes, please supply the information below if available.
	Name of referring doctor ______________________________Referring doctor’s telephone #:____________________

11. I certify that the above statements, in my opinion, truly describe the patient’s disability and the estimated duration thereof:
____________________________________________					_______________________________________ ______________________
	(Print Doctor’s Name and Medical Degree)				(Original Signature of Doctor Required)				(Date Signed)
_______________________________________________________					_____________________________________________________				If Resident, check
(Address)						(Certificate License No. and State)
_______________________________________________________________						____________________________________________________________________
(Address)							(Specialty of Treating Physician)
______________________________________________________________
(City)		(State)		(Zip Code)
Telephone Number: (		)______________________________					FAX Number: (	)_______________________________

						3 OF 4

1. Claimant’s Name: _______________________________Clt’s Tele #(____)______________

Clt’s Address:__________________________________________________________________

SOCIAL SECURITY NUMBER

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PART C

TO BE COMPLETED BY YOUR EMPLOYER OR COMPANY REPRESENTATIVE

WDS-1(R-2-08)

2. EMPLOYER STATUS

8. BASE WEEKS AND BASE YEAR GROSS

What is your Federal Employer Identification Number: ___________________

WAGES A BASE WEEK is a calendar week in

3. PRIVATE PLAN COVERAGE (NJ approved plan/replaces State Plan coverage)

which the claimant had New Jersey earnings of $143

a. Do you have a New Jersey approved Private Plan?

Yes

or more during the Base Year. The BASE YEAR is

b. If “Yes”, is claimant covered under this approved Private Plan?

Yes

the 52 calendar weeks preceding the week in which

4. LAST ACTUAL DAY WORKED before this disability

the disability occurred.

(do not use payroll week ending dates)

______|______|______

(Month

Day

Year)

a. Total Number of Base Weeks _______________

a. Reason for separation from work if other than

disability _____________________________________________________

b. Total Gross Wages in Base Year ____________

b. Is lack of work:

temporary?

permanent?

Include all wages earned by the claimant

c. Has claimant returned to work?

Yes

__________________________________________

If “Yes”, give date

_______|_____|______

(Month

Day

/ Year)

9. REGULAR WEEKLY WAGE $_____________

d. If the work was intermittent, list dates:_______________________________

5. CONTINUED PAY (do not enter wages earned prior to disability)

10. Weekly wages

a. Have you paid or expect to pay the claimant for any period after the last day

Indicate below: dates and claimant’s GROSS

of work?

Yes

earnings in N.J. employment during the listed

b. If “yes” give dates:

FROM ______|_____|_____ TO _____|_____|_____

calendar weeks.

Month /

Day /

Year)

(Month / Day / Year)

c. Amount per week $______________, if amount varies attach list of dates

Description of

Calendar

Gross

Calendar Week

Week

Wages

and amounts.

Ending Date

d. Check the number that best describes the monies paid in item c.

Week Disability

1. Regular weekly wages and/or sick pay

Began

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

Week Before

3. Pension

Disability

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

2nd Week Before

received

Disability

5. Full salary advanced to effect #4 above

3rd Week Before

6. Supplemental benefits or gratuities

Disability

Note: Items 1, 2, and 3 may reduce benefits to the claimant

4th Week Before

6. GOVERNMENT EMPLOYEES (Complete this section)

Disability

a. Payroll number (For N.J. State Employees) ________________________

5th Week Before

b. Number of earned sick leave days as of the last day worked. ___________

Disability

c. Has the claimant filed for or received Employment Disability Leave

6thWeek Before

(SLI)?

Yes

Disability

d. If claimant has applied for or received donated leave, attach dates and

amounts on a separate sheet of paper.

7th Week Before

7. WORKERS’ COMPENSATION LIABILITY

Disability

a. Did the claimant’s disability happen in connection with his/her work or

8th Week Before

while on your premises, or was the disability due in any way to his/her

Disability

occupation?

Yes

9th Week Before

b. If “Yes”, have you filed or do you intend to file a Workers’ Compensation

Disability

claim on behalf of this claimant?

Yes

10th Week Before

c. If “Yes,” list Workers’ Compensation insurance carrier below:

Disability

Name______________________________Telephone (

) _______________

Address__________________________________________________________

TOTAL GROSS WAGES FOR

ABOVE WEEKS

Policy #_______________________ Claim #___________________________

Are you exempt from FICA tax?

Yes

11. Check the days of the week the employee normally works. SUN

MON

TUE

WED

THUR

FRI

SAT

Firm Name __________________________________________I CERTIFY THE INFORMATION GIVEN ABOVE IS CORRECT

Address ____________________________________________ Signed_____________________________Date___________________

City, State, Zip_______________________________________ Print or Type Name _________________________________________

Mailing Address, If Different____________________________ Official Title_______________________________________________

FAX No. ( ) _______________________ Telephone (

) _____________________E-Mail Address_______________________

4 OF 4

Question	Answer
Form Name	Form Wds 1 R 2 08
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	NJ, THUR, 12a, 7th

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