ࡱ> { bjbjzz =((((,(+6Y!d"5555555$7:v@5$$$@55((($ 5($5((/+21A$0550+604:$: 21:21q#>#,(#$#q#q#q#@5@5C(jq#q#q#+6$$$$:q#q#q#q#q#q#q#q#q# : State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS COMPENSATION WC(DO)-370 Interactive(r. 4/24/13)ORDER APPROVING SETTLEMENT WITH DISMISSAL N.J.S.A. 34:15-20 CASE NO S.:  FORMTEXT       VICINAGE:  FORMDROPDOWN  PETITIONERNAME:  FORMTEXT       ATTORNEY FOR PETITIONERFEDERAL EMPLOYER NUMBER  FORMTEXT      DATE OF BIRTH:  FORMTEXT      MEDICARE ELIGIBLE:  FORMCHECKBOX  YES  FORMCHECKBOX  NONAME:  FORMTEXT      ADDRESS:  FORMTEXT       ADDRESS:  FORMTEXT       RESPONDENTvsTELEPHONE NUMBER (AREA CODE):  FORMTEXT      NAME:  FORMTEXT      APPEARING:  FORMTEXT      ADDRESS:  FORMTEXT       INSURANCE CARRIERNAME  FORMCHECKBOX  SELF-INSURED  FORMCHECKBOX  TPA  FORMTEXT      ATTORNEY FOR RESPONDENTNAME:  FORMTEXT      ADDRESS:  FORMTEXT       ADDRESS:  FORMTEXT      CLAIM NUMBER:  FORMTEXT      TELEPHONE NUMBER (AREA CODE):  FORMTEXT       APPEARING:  FORMTEXT        This is a lump sum settlement between the parties in the amount of $ FORMTEXT       pursuant to N.J.S.A. 34:15-20 which has the effect of a dismissal with prejudice, being final as to all rights and benefits of the petitioner and is a complete and absolute surrender and release of all rights arising out of this/these claim petitions(s). The payment hereunder shall be recognized as a payment of workers compensation benefits for insurance rating purposes only. The parties agree that this settlement [  FORMCHECKBOX  does (complete page 2) /  FORMCHECKBOX  does not] contemplate a complete and absolute surrender and release of any and all rights by the petitioners dependents as defined by N.J.S.A. 34:15-13 arising out of this/these claim petition(s).  FORMCHECKBOX Order for Child Support Attached FORMCHECKBOX Addendum attached FORMCHECKBOX Further Agreed:  FORMTEXT       ALLOWANCESREIMBURSETAX IDENTIFICATION NUMBERTOTAL AMT. ALLOWEDPAYABLE BY PETITIONERPAYABLE BY RESPONDENTMEDICAL FEE ALLOWED: (report and/or testimony)  FORMTEXT        FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      ATTORNEY(S) FEE:  FORMTEXT       FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      STENOGRAPHIC SERVICE:  FORMDROPDOWN   FORMTEXT       FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      MISCELLANEOUS FEES:  FORMTEXT       FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Reason(s) for Section 20 (check all that apply): Contested issues regarding:  FORMCHECKBOX JURISDICTION  FORMCHECKBOX  LIABILITY  FORMCHECKBOX  CAUSAL RELATIONSHIP  FORMCHECKBOX  DEPENDENCY WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY:After considering the circumstances, I find this settlement fair and just.  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#Q#\#]#^#h#i#$øwh^LhJU"jCh,>h,>5UaJh,>h,>5aJjh,>h,>5UaJh>CJ aJh .HCJ aJh2h .HCJ aJh2hm@CJ aJhl]CJaJh .HCJaJhc&mhm@CJaJhc&mhm@CJaJh#hUgCJaJ&jAh!>Wh\5CJUaJ jh!>Wh\5CJUaJh!>Wh\5CJaJ "!"""z"{""""{rriii $Ifgdm@ $IfgdFgd nkdB$$Ifl+(, t0644 lap yt!>Wd$If]gd!>W""""""}} $If^gdF $IfgdFkkdB$$Ifl4|F+*` t,    44 laytO""""""\#]# $Ifgd .H $IfgdFkkd C$$Ifl4F+*  t,    44 laytO     PETITIONER (where applicable) JUDGE S NAME THE ORIGINAL OF THIS DOCUMENT, SIGNED BY THE JUDGE OF COMPENSATION, WILL BE MAINTAINED ON FILE IN THE DIVISION OF WORKERS COMPENSATION, PURSUANT TO N.J.S.A. 34:15-121 et. seq. RESPONDENT S ATTORNEY State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS COMPENSATION WC(DO)-370 Interactive(r. 4/24/13)ORDER APPROVING SETTLEMENT WITH DISMISSAL N.J.S.A. 34:15-20 Page 2 CASE NO S.:  REF Text1   VICINAGE:  REF Dropdown1   The parties agree that this settlement does contemplate a complete and absolute surrender and release of any and all rights by the petitioner s dependents as defined by N.J.S.A. 34:15-13 arising out of this/these claim petitioner(s). As the spouse or other person who may be defined as a dependent under N.J.S.A. 34:15-13 or the guardian or representative of such a person, I (we) consent to the entry of this order and recognize that this agreement is a complete and absolute surrender of any rights that I (we) may have pursuant to N.J.S.A. 34:15-13, should petitioner die as a result of the injuries, conditions, or exposures alleged in this/these claim petition(s).  Name Date  FORMTEXT      Name Date  FORMTEXT      On Behalf of On Behalf of Name Date  FORMTEXT      Name Date  FORMTEXT      On Behalf of On Behalf of Name Date  FORMTEXT      Name Date  FORMTEXT      On Behalf of On Behalf of  I certify that the above is (are) the only individual(s) who is (are) dependent(s) as defined in N.J.S.A. 34:15-13 at the present time. _________________________________________________________ Petitioner Date WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY:After considering the circumstances, I find this settlement fair and just.  PETITIONER S ATTORNEY JUDGE OF COMPENSATION DATE  REF Text116  PETITIONER (where applicable) JUDGE S NAME THE ORIGINAL OF THIS DOCUMENT, SIGNED BY THE JUDGE OF COMPENSATION, WILL BE MAINTAINED ON FILE IN THE DIVISION OF WORKERS COMPENSATION, PURSUANT TO N.J.S.A. 34:15-121 et. seq. 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