Nj Temporary Disability Form – Fill Out and Use This PDF

It's easy to provide employees with the payment they need while on temporary disability leave—all one has to do is fill out the NJ Temporary Disability Form. All information must be true inf order for employees to receive payments on time. This invaluable document captures employee data, including their earnings for a designated period of time and other particulars related to their absence from work due to sickness or injury. Once complete, employers can submit this form directly to the Disability Benefits mailing address as stated in official communication from New Jersey's Division of Temporary Disability Insurance. Once that requirement is seen through, there won't be any further roadblocks on creating a comfortable and secure environment for those in need!

Nj Temporary Disability Form PDF Details

Are you applying for short-term disability in the state of New Jersey? If so, you need to complete and submit a NJ Temporary Disability Form. Here, we’ll break down the requirements, how to fill out the forms correctly and how to submit your temporary disability paperwork successfully. We’ll also discuss what happens once all documents have been received by your insurance carrier and when you can expect to receive payments. Keep reading for more insight into filing a New Jersey Short Term Disability application!

Question	Answer
Form Name	Nj Temporary Disability Form
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	nj disability form, disability forms nj, form ds1, nj temporary disability

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DIVISION OF TEMPORARY DISABILITY INSURANCE

CLAIM FOR DISABILITY BENEFITS (DS-1)

DETACH THIS PAGE AND KEEP FOR YOUR RECORDS

CLAIMANT RIGHTS AND RESPONSIBILITIES

RULES FOR FILING A CLAIM AND APPEAL RIGHTS

1.It is your responsibility to file this claim form promptly after you stop working due to your disability. Filing your claim before your last day of work will delay its processing. The law requires that claims must be filed within 30 days after the beginning of the disability. Benefits may be denied or reduced if the claim is filed late. If your claim is filed beyond the thirty day period, please use the space provided on the reverse side of Part A to give your reasons for the late filing.

2.If you disagree with a determination on your claim and wish to appeal, you must do so in writing within ten days from the date the decision was mailed. You do not need a lawyer at the appeal hearing.

CLAIMANT RESPONSIBILITIES:

1.Your signature certifies that you understand any misrepresentation of fact or failure to disclose a material fact may be punishable under the law. This includes any changes to the Medical Certificate or the Employer’s Statement made by you without authorization by your physician or your employer.

2.You must inform us of any other payments you are receiving such as sick pay or wages, a pension from your last employer, worker’s compensation benefits, Social Security Disability benefits, or disability benefits from your employer or union.

3.If you receive a request for continued medical certification (Form P30), you must have your physician complete and sign the form. You should return it promptly.

4.When you recover or return to work, you must report this date immediately to the Division of Temporary Disability Insurance.

5.If you are requesting voluntary Federal Income Tax (F.I.T.) deductions to be withheld from your disability benefits, attach Form W-4S (Request for Federal Income Tax Withholding From Sick Pay) to your claim. Forms should be obtained from your employer or the Internal Revenue Service.

6.If your home and/or mailing address changes, you must notify the Division of Temporary Disability Insurance, PO Box 387, Trenton, NJ 08625-0387 immediately in writing. Notification must include your Social Security Number and signature.

CLAIM ASSISTANCE:

If you require any assistance with your claim, call:

•Customer Service Section (609) 292-7060.

•Telecommunication Device for the Deaf (TDD) (609) 292-8319

•New Jersey Relay Service: TT user 1-800-852-7899

Voice User: 1-800-852-7897

Important: Please allow fourteen (14) days processing time before inquiring about your claim.

Division of Temporary Disability Insurance FAX number: (609) 984-4138

For additional information about the Temporary Disability Benefits Program, visit our website at: www.nj.gov/labor

NOTE: If your disability is expected to last for one year or longer, you may be eligible for Federal Social Security Disability Benefits.

Toll Free number for Social Security: 1-800-772-1213.

Please print or type your Social Security Number CLEARLY. An incorrect or illegible number will cause a delay in processing your claim.

You must complete this item. If your answer to this question is “No,” you must complete Items 10 and 11 and give your country of origin.

Please give exact dates. Remember to include the dates of any Emergency Room care you may have received for this disability. If available, provide proof of emergency room care.

List the name and address of the physician who treated you for this disability. You must be under the care of a legally licensed physician, dentist, optometrist, podiatrist, practicing psychologist, chiropractor or advanced practice nurse. If you have been treated by more than one physician, use the additional space provided on the reverse side of Part A to list their names and addresses.

Starting with your most recent employer, list all employers, including those for whom you worked part-time, for the last 18 months. If you had more than two employers, list the others with the dates you worked in the space provided on Part A1. Give business names and addresses as they appear on your pay envelopes, pay checks, employers’ stationery or as listed in the telephone book.

Include your full name and complete address (this information is required). If your mailing address is different than your home address, be sure to complete Item 6.

READ THE FOLLOWING INSTRUCTIONS BEFORE COMPLETING THE ATTACHED FORM,

CLAIM FOR DISABILITY BENEFITS – DS-1

1.Complete both sides of the claimant’s portion of this form (Part A & A1.) YOU ARE RESPONSIBLE for having Part B completed by your doctor and Part C by your last employer. If you have worked for more than one employer during the past year, you may copy Part C for completion by the other employer(s) to avoid processing delays. Any missing or incorrect entries on this form will delay processing of your claim. If you cannot have Parts B and/or C completed timely, complete Part A and A1 and return the application as soon as possible.

REMEMBER SENDING IN SEPARATE PARTS OF THE APPLICATION WILL DELAY YOUR CLAIM. NOTE: IF YOU CHOOSE TO FAX THIS FORM TO OUR OFFICE, BE SURE TO COPY THE BACK SIDE OF EACH PAGE AND FAX ALL FOUR PAGES AND ANY OTHER ATTACHMENTS. MAIL OR FAX PART A, PART A1, PART B AND PART C TOGETHER TO:

Division of Temporary Disability Insurance PO Box 387

Trenton, NJ 08625-0387

FAX No: (609) 984-4138

2.Read all questions carefully! Print or write clearly since this information is used to determine your right to benefits. If you need any assistance in completing this form, please call the Customer Service Section in Trenton at (609) 292-7060 and hold for an agent.

3.BE SURE TO WRITE YOUR SOCIAL SECURITY NUMBER AND NAME ON EACH PORTION OF YOUR CLAIM.

Instructions For Part A and A1 – Claimant’s Statement – Please complete all questions Items 1, 4 & 6

Item 3

Item 9

Items 12 –15

Item 18

Item 19

Part A1

In the event that you are unable to telephone our agency, you may designate a

Item 1 representative in this space to obtain information on your behalf. If there is no one listed, only YOU will be able to obtain information on your claim from this agency.

Item 2 Sign and date the claim form. Include your telephone number.

Important: We suggest that you keep a copy of the completed claim form for your records.

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-3-11)

1. Name: Last	First	Middle	2. Birth Date
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

WDS-1 (R-3-11)

Claimant’s Name:_________________________________________

Claimant’s Telephone No: (_____)___________________________

Social Security Number

| |

	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.

WDS-1(R-3-11)

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: (	)_______________________________

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

Clt’s Address:__________________________________________________________________

SOCIAL SECURITY NUMBER

| |

PART C

TO BE COMPLETED BY YOUR EMPLOYER OR COMPANY REPRESENTATIVE

WDS-1(R-3-11)

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 $145

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)

Description of

Calendar

Gross

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

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

6th Week Before

(SLI)?

Yes

Disability

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

7th Week Before

amounts on a separate sheet of paper.

Disability

7. WORKERS’ COMPENSATION LIABILITY

8th Week Before

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

Disability

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

9th Week Before

occupation?

Yes

Disability

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

claim on behalf of this claimant?

Yes

10th Week Before

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

Disability

Name______________________________Telephone (

) _______________

TOTAL GROSS WAGES FOR

Address__________________________________________________________

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_______________________

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Step number 1 of filling in nj form disability

2. When the last array of fields is complete, you have to insert the needed particulars in Name Last First Middle Home, Birth Date, Social Security Number, County, Male Female, Occupation, Are you a citizen of the United, Alien Reg No, Work Authorization From To Year, Month, Day, IllnessAccidentMaternity, and a What was the last day that you so you're able to move forward to the 3rd part.

Filling in segment 2 in nj form disability

3. The following part will be focused on Was this injuryillness caused by, This question must be answered, or No, or No, Identify the physician or, Period of employment From To, Occupation Full time Check the, Part time, Union Division, MON, TUE, WED, THUR, FRI, and SAT - complete each one of these fields.

Part number 3 for filling out nj form disability

4. This next section requires some additional information. Ensure you complete all the necessary fields - Occupation Full time Check the, Period of employment From To, Part time, Union Division, Check the days of the week you, MON, TUE, WED, THUR, FRI, SAT, Other Benefits You Must Answer, No No No, Since your last day of work have, and employer or union Yes e - to proceed further in your process!

nj form disability completion process clarified (part 4)

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Nj Temporary Disability Form – Fill Out and Use This PDF

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