Forms and Publications
Browse Workers’ Compensation forms and publications below.
|
BROCHURES AND PUBLICATIONS |
Doc # |
Word |
|
Version |
|
Workers' Compensation Statute |
|
3/23 |
||
|
Workers' Compensation Rules |
|
1/18 |
||
|
A Workers' Guide to Workers' Compensation in New Jersey (legal size paper) |
wc(g)-338 |
|
6/22 |
|
|
Guia Interpretativa para el Trabajador A la Ley de Compensacion al Trabajador en Nueva Jersey (legal size paper) |
wc(g)-338s |
|
1/16 |
|
|
Uninsured Employers Fund Pamphlet: provides the regulations associated with the Uninsured Employers Fund (legal size paper) |
scf-122 |
|
11/02 |
|
|
Second Injury Fund - A Beneficiary's Guide: provides necessary information to recipients of second injury fund benefits. (legal size paper) |
scf-103 |
|
1/11 |
|
|
Fondo De Segunda Incapacidad - Guia del Beneficiario |
scf-103s |
|
1/11 |
|
|
WC Research Manual - link to the instructions page |
|
|
|
7/11 |
|
EMPLOYEE / WORKER FORMS |
Doc # |
Word |
|
Version |
|
Application for Informal Hearing |
wc-66 |
|
6/06 |
|
|
Discrimination Complaint Form |
scf-4 |
|
7/04 |
|
|
Report of Non-Compliance (online): submit this form to report an uninsured employer |
|
|
|
8/22 |
|
EMPLOYER / INSURANCE CARRIER FORMS |
Doc # |
Word |
|
Version |
|
NJ Benefit Letter - Medical Only: document maintained at the Compensation Rating and Bureau (NJCRIB) website |
|
|
|
|
|
NJ Benefit Letter - Indemnity: document maintained at the Compensation Rating and Bureau (NJCRIB) website |
|
|
10/7/04 |
|
|
NJ Benefit Letter Usage Directions: document maintained at the Compensation Rating and Bureau (NJCRIB) website |
|
|
10/7/04 |
|
|
Employer Notice of Workers' Compensation Insurance Coverage: this link will take you to the NJ Compensation Rating & Inspection Bureau's website. |
|
|
||
|
|
|
3/23 | ||
|
|
|
3/23 |
|
FORMAL LITIGATION FORMS |
Doc # |
Word |
|
Version |
|
Petitioner Forms |
||||
|
Employee's Claim Petition (can be used for Amended CP) |
wc-365 |
|
8/26/15 |
|
|
Employee's Claim Petition Supplemental Page |
wc-365.1 |
|
5/7/15 |
|
|
Application for Review or Modification of Formal Award (can be used for Amended ReOpener) Reopener Supplemental Page |
wc-368
wc-368_Supp |
|
8/26/15 |
|
|
Dependency Claim Petition (can be used for Amended DCP) DCP Supplemental Page |
wc-366 DWCsupp |
|
8/26/15 |
|
|
Dependency Claim Petition To Convert Voluntary Tender to Formal Judgment |
wc-956 |
|
12/19 |
|
|
Notice of Motion for Temporary and/or Medical Benefits (fillable) |
wc-101_i |
3/07 |
||
|
Standard petitioner's occupational interrogatory form |
wc-22 |
|
|
|
|
Second Injury Fund Verified Petition (fillable) |
scf-161_i |
|
3/22 |
|
|
Social Security Offset Calculation |
scf-16 |
|
5/95 |
|
|
Medical Provider Application for Payment or Reimbursement of Medical Payment |
wc-381 |
|
8/26/15 |
|
|
Uninsured Employer's Fund Information Packet |
|
|
9/7/07 |
|
|
Motion for Emergent Medical Treatment |
wc-383 |
|
5/14 |
|
|
Application for Commutation |
wc-60 |
|
6/07 |
|
|
Respondent Forms |
||||
|
Respondent's Answer to Claim Petition (can be used for Amended Answer) |
wc-367 |
|
5/15 |
|
|
Respondent's Answer to Application for Review & Modification of Formal Award (can be used for Amended Answer) |
wc-369 |
|
6/15 |
|
|
Respondent's Answer to Dependency Claim Petition |
wc-171 |
|
7/04 |
|
|
Answering Statement for Motion for Medical and/or Temporary Benefits (fillable) |
wc-170 |
3/07 |
||
|
Respondent's Answer to Medical Claim Petition |
|
|
7/10 |
|
|
Standard respondent's occupational interrogatory form |
wc-23 |
|
|
|
|
Petitioner and Respondent Forms |
||||
|
Request for Adjournment / Ready Hold - page 1 (fillable) Request for Adjournment / Ready Hold - additional page |
|
|
6/30/16 |
|
|
Substitution of Attorney |
wc-10 |
|
8/04 |
|
|
Subpoena Duces Tecum Ad Testificandum |
wc-18 |
|
4/06 |
|
|
Subpoena Ad Testificandum |
wc-18.1 |
|
4/06 |
|
|
Subpoena Duces Tecum |
wc-18.2 |
|
4/06 |
|
|
Request for Social Security Information |
wc-124 |
|
6/04 |
|
|
Pre-Trial Memorandum |
wc-31 |
|
5/12 |
|
|
Notice of Motion (fillable) |
wc-7 |
12/07 |
||
|
Trial Scheduling Order (fillable) |
wc-16 |
|
6/07 |
|
|
Second Injury Fund Information Review Sheet (fillable) |
wc-380 |
|
6/08 |
|
|
SETTLEMENT FORMS |
Doc # |
Word |
|
Version |
|
Judgment / Order Approving Settlement (fillable) (with Case Exhibit Listing) |
WC-100i |
|
9/23/15 |
|
|
Order for Dismissal (fillable) |
WC-100Dismissal_i |
7/13 |
||
|
Generic Order (for Miscellaneous Decisions, Motions, etc.) (fillable) |
WC-100Generic |
7/13 |
||
|
Order Approving Settlement under NJSA 34:15-20: (fillable) (page 1 and 2) |
WC-370_i |
4/13 |
||
|
Amended Order (fillable) |
wc-8 |
|
8/09 |
|
|
Order for Distribution (for child support) |
wc103 - wc103.1 |
|
4/06 |
|
|
Order for Distribution of Temporary Award (for child support) |
wc379 - wc379.1 |
|
4/06 |
|
|
Affidavit of Dependent in Support of Settlement Under N.J.S.A. 34:15-20 |
wc-366.1 |
|
9/9/05 |
|
|
Decision of Dismissal (Second Injury Fund) |
wc-47 |
|
1/17 |
|
|
Order for Total Disability (fillable) |
wc-374 _i |
9/15 |
||
|
Order for Total Disability with SS Offset (fillable) |
wc-375_i |
12/15 |
||
|
Order for Total Disability with SIF (fillable) |
wc-376_i |
12/15 |
||
|
Addendum to Order for Total Disability (fillable) |
wc-377_i |
12/15 |
|
SCHEDULES OF DISABILITIES |
Doc # |
Word |
|
Version |
|
Calendar Year 2023 |
|
|
|
|
|
Calendar Year 2002 |
|
|
|
|
|
Calendar Year 2003 |
|
|
|
|
|
Calendar Year 2004 |
|
|
|
|
|
Calendar Year 2005 |
|
|
|
|
|
Calendar Year 2006 |
|
|
|
|
|
Calendar Year 2007 |
|
|
|
|
|
Calendar Year 2008 |
|
|
|
|
|
Calendar Year 2009 |
|
|
|
|
|
Calendar Year 2010 |
|
|
|
|
|
Calendar Year 2011 |
|
|
|
|
|
Calendar Year 2012 |
|
|
|
|
|
Calendar Year 2013 |
|
|
|
|
|
Calendar Year 2014 |
|
|
|
|
|
Calendar Year 2015 |
|
|
|
|
|
Calendar Year 2016 |
|
|
|
|
|
Calendar Year 2017 |
|
|
|
|
|
Calendar Year 2018 |
|
|
|
|
|
Calendar Year 2019 |
|
|
|
|
|
Calendar Year 2020 |
|
|
|
|
|
Calendar Year 2021 |
|
|
||
|
Calendar Year 2022 |
|
|
|
ELECTRONIC CALENDARS, COURTS ON-LINE AND ELECTRONIC FILING FORMS |
Doc # |
Word |
|
Version |
|
Electronic Calendars |
||||
|
Attorney Calendar E-mail Program application (fillable): this form initiates the transmission of "Attorney Calendar" scheduling notices via e-mail to designated e-mail address(es). |
|
|
7/5/22 |
|
|
COURTS on-line |
||||
|
COURTS on-line Internet Access Application (fillable): this application package needs to be completed if a law firm, insurance carrier or self-insured is interested in accessing COURTS on-line, the Division's on-line case management website. Package contains both the Designation of Contact form and Subscriber application form. |
|
3/22 |
||
|
Subscriber Application only (fillable): this form needs to be completed if a law firm, insurance carrier or self-insured is interested in adding an additional subscriber to access COURTS on-line and the firm has already established a Contact Person with the Division. This form must be signed by both the subscriber and the firm’s Contact Person prior to submitting. |
|
|
|
|
|
COURTS on-line Subscriber Change Form (fillable): this form needs to be completed if an existing COURTS on-line subscriber has had a change to their name or e-mail address or if their e-filing access level request has changed. The form must be signed by the firm's Contact Person prior to submitting. |
|
7/19/13 |
||
|
Electronic Filing |
||||
|
E-Filing Procedures Guide |
|
|
6/26/12 |
|
|
E-Filing Motions Procedures Guide |
|
|
7/16/14 |
|
|
MISCELLANEOUS FORMS |
Doc # |
Word |
|
Version |
|
Uninsured Employer's Fund Information Packet |
|
|
9/7/07 |
|
|
Request for Records Inspection: this form must be completed and signed before the Division can release records. |
wc-147 |
|
6/2014 |
|
|
Report of Non-Compliance (online): this form may be used by any individual or organization to report allegations of failure on the part of an employer to maintain workers' compensation insurance coverage or obtaining authorization to self-insure. |
|
|
|
8/22 |
|
Insurance Carrier Contact form (online): this form to designate a contact person must be completed by every insurance carriers and self-insurer authorized to do business in NJ. |
|
|
|
4/22 |
|
Insurance Carrier / Self-Insurer Contact Listing: these individuals can be contacted by judicial staff and attorneys where there has been no appearance or formal response made by the carrier or their counsel on pending Motions for Medical and Temporary Benefits. |
|
|
8/22/22 |
|
|
Public Sector Contact Listing: similar to above listing |
|
|
8/22/22 |
|
|
Hearing Cycle Calendar |
|
|
3/22 |