ࡱ> #% !"{ 6bjbjzz 7:"((((,(?.4 %%%%%fU)!+>>>>>>>ACv>-%%-->%%?Y6Y6Y6- %%>Y6->Y6Y6r:;% UKA-.;>?0?;>D->D;>D; ,Zc,@Y6,4, , , ,>>w5 , , ,?---->D , , , , , , , , , : State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS COMPENSATION WC-375i (r. 3/19/13)ORDER FOR TOTAL DISABILITY w/Social Security Offset CASE NO S.:  FORMTEXT       VICINAGE:  FORMDROPDOWN  PETITIONERSOCIAL SECURITY NUMBER:  FORMTEXT      ATTORNEY FOR PETITIONER FORMCHECKBOX  SSN  FORMCHECKBOX  FEDERAL EMPLOYER NUMBER  FORMCHECKBOX  NJ REG NUMBER  FORMTEXT      NAME:  FORMTEXT      NAME::  FORMTEXT      DATE OF BIRTH:  FORMTEXT      MEDICARE ELIGIBLE:  FORMCHECKBOX  YES  FORMCHECKBOX  NOADDRESS:  FORMTEXT       ADDRESS (Including County):  FORMTEXT       TELEPHONE NUMBER (AREA CODE):  FORMTEXT       RESPONDENTvsAPPEARING:  FORMTEXT      NAME:  FORMTEXT      ADDRESS (Including County):  FORMTEXT        INSURANCE CARRIERNAME :  FORMCHECKBOX  SELF-INSURED  FORMCHECKBOX  TPA  FORMTEXT      CLAIM NUMBER;  FORMTEXT      ATTORNEY FOR RESPONDENTNAME:  FORMTEXT      DATE OF ACCIDENT OR OCCUPATIONAL EXPOSURE:  FORMTEXT      ADDRESS:  FORMTEXT      DESCRIBE (Briefly):  FORMTEXT      TELEPHONE NUMBER (AREA CODE):  FORMTEXT       APPEARING:  FORMTEXT       Weekly Wages $  FORMTEXT      Rate(s) $  FORMTEXT       / $  FORMTEXT       IF RE-OPENED PETITION, INDICATE FOR LAST AWARD: DATE:  FORMTEXT       PERMANENT: $  FORMTEXT       TEMP: $  FORMTEXT       This matter having come before the COURT on this  FORMTEXT       day of  FORMDROPDOWN ,  FORMDROPDOWN  :   FORMCHECKBOX ORDER FOR JUDGMENT It appearing that the Petitioner suffered a compensable injury on the above mentioned date while in the employ of respondent . It is Ordered and Adjudged that Petitioner be awarded compensation benefits, payable as set forth below.  FORMCHECKBOX ORDER APPROVING SETTLEMENT The parties having settled the matter and a finding by the Court having been made that the terms of the settlement are fair and just; It is Ordered that this settlement be approved and the petitioner be paid as set forth below. PERMANENT DISABILITY:  FORMTEXT       State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS COMPENSATION WC-375iORDER FOR TOTAL DISABILITY w/Social Security Offset Page 2 CASE NO S.:  REF Text1 \* MERGEFORMAT   VICINAGE:  REF Dropdown1   AWARD WITHOUT SOCIAL SECURITY OFFSETSTEMPORARY:  FORMTEXT       Weeks at $ FORMTEXT       = $ FORMTEXT      less $ FORMTEXT       paid = Balance due $ FORMTEXT      PERMANENT:  FORMTEXT       Weeks at $ FORMTEXT       = $ FORMTEXT      less $ FORMTEXT       paid = Balance due $ FORMTEXT       FORMCHECKBOX  Voluntary Tender  FORMCHECKBOX  Reopener Credit PAYMENTS DUE FROM RESPONDENT WITH SOCIAL SECURITY OFFSETSPayments before offset begins FORMTEXT      weeks at $ FORMTEXT      less $ FORMTEXT      Paid = $ FORMTEXT      +Payments with offset (aux) FORMTEXT      weeks at $ FORMTEXT      less $ FORMTEXT      Paid = $ FORMTEXT      +Payments with offset (no aux) FORMTEXT      weeks at $ FORMTEXT      less $ FORMTEXT      Paid = $ FORMTEXT      +After offset completed FORMTEXT      weeks at $ FORMTEXT      less $ FORMTEXT      Paid = $ FORMTEXT      TOTAL PAYMENTS$ FORMTEXT       MEDICAL BILLS (Doctors and/or Institutions):  FORMTEXT       Petitioner is in receipt of Social Security Disability Benefits and the initial date of entitlement was  FORMTEXT       . Petitioner s 80% ACE is  FORMTEXT       and petitioner s initial entitlement was $  FORMTEXT       including $  FORMTEXT       for auxiliary beneficiaries. Therefore respondent is entitled to an offset resulting in a rate of $  FORMTEXT       until petitioner s last auxiliary graduates from high school or turns 18 years of age, whichever is later. Thereafter, until the petitioner reaches 62 years of age on  FORMTEXT       the offset rate shall be $  FORMTEXT       . 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"68:DFJL`bdnprtʨִ֤֔֋rhh)hNd>*aJjh)hNd>*UaJh)h3>*aJh)h3aJj[bh)h?UaJjah)h?UaJj`h)h?UaJjH`h)h?UaJUh)h?aJ$jh)hCUaJmHnHujh)h?UaJ&++ Hrdd $$Ifa$gd)K$kd_$IfK$L$Ts0\wW t044 sapyt)TRMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       The first  FORMTEXT       weeks of permanent disability are to be paid at the full rate of $  FORMTEXT       reflecting Petitioner s share of counsel fee and costs. In the event there is a change in the number or status of the auxiliary beneficiaries while Petitioner is receiving Workers Compensation benefits, Petitioner shall immediately notify the Respondent. I further Order that Respondent furnish the Petitioner such medical attention, prosthesis, and medical supplies as the condition of the Petitioner may require. Should any emergency arise, necessitating immediate medical attention for the Petitioner, notice and request to Respondent shall not be necessary.  FORMCHECKBOX  Respondent authorizes  FORMTEXT       as treating physician.  State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS COMPENSATION WC-375iORDER FOR TOTAL DISABILITY w/Social Security Offset Page 3 CASE NO S.:  REF Text1   VICINAGE:  REF Dropdown1 \* MERGEFORMAT   The date of Petitioner s Permanent Total disability is  FORMTEXT       . On  FORMTEXT       , which is the expiration of the 450 week period, benefits to continue in accordance with the provision of N.J.S.A. 34:15-12(b) as amended. Pursuant to N.J.S.A. 34:15-12(b), petitioner will be referred to the Division of Vocational Rehabilitation Services for evaluation and services prior to the expiration of 450 weeks from the date of Total Permanent Disability.  REIMBURSETAX IDENTIFICATION NUMBERTOTAL AMT. ALLOWEDPAYABLE BY PETITIONERPAYABLE BY RESPONDENTMEDICAL FEE ALLOWED: (expert and/or testimonial)  FORMTEXT        FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT        FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       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        REF Text101 \* MERGEFORMAT   FORMTEXT       FORMTEXT       FORMTEXT      STENOGRAPHIC SERVICE:  FORMDROPDOWN   FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      MISCELLANEOUS FEES: (fill in below)  FORMTEXT        FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT   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