Fillable Printable Claimant Rights and Responsibilities - New Jersey

Claimant Rights and Responsibilities - New Jersey

DIVISION OF TEMPORARY DISABI LI TY I NSURANCE

CLA IM FOR DISABIL ITY B ENEFITS (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

Dis abili t y Insu rance.

5. If you are requesting voluntary Federal Income Tax (F.I.T.) deductions to be withheld from your disability

benefi t s, att ach 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.

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.

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

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.

Item 3

Please print or type your Social Security Number CLEARLY. An incorrect or illegible

number will cause a delay in processing your claim.

Item 9

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.

Items 12 –15

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.

Item 18

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, certified nurse midwife 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.

Item 19

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.

Part A1

Item 1

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

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.

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 Ins

urance

PO Box 387

Trenton, NJ 08625-0387

FAX No: (609) 984-4138

STATE O F NEW JER SEY – DEPARTM ENT OF LA BOR AND WORKFORCE DEVELOPMENT

DIVISION OF TEMPORARY DISABI LI TY I NSURANCE

PART A INFORMATION TO BE COMPLETED BY THE CLAIMANT – Print or Type WDS-1(R-12-14)

1. Name: Last First Middle

2. Birth Date

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3.Social Security Number

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4. Ho me Address – required ( Street, Apt # , City, State, Zip Co de)

5. County

6. Mail ing Addr e ss – if different (Stre e t, Apt #, City, State, Zip Cod e )

7.Male

Female

8. Occupation

9. Are you a citizen of the United States? Yes No

If NO, answer #10 & 11 and give country of origin: ______________

10. Alien Reg. No.

11. Work Authorization

From ___________ To ___________

12 a . What wa s the last day that you actually worked before your disability began?

12b. Reason for separation: I llness/ Accid ent/Maternity Terminate d Quit

Month

Day

Year

13. W hat was the first day you were unable to work due to prese nt disa bility:

(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 fu ture)

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

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

16. Descr ibe yo ur disabili ty (How, w hen, whe re it happene d) _________________________________________________________

________________________________________________________________________________________________________________________________________

17. Was this injury/ illness cau sed by your jo b? Ye s or No (This question must be answered.)

If Yes, date of work related injury/ illness:_________________

W as your empl oyer not if ied t hat your injury wa s caused by your job? Yes

or No

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

Address: ____________________________________________________________ Telephone: (_____)_________________________

Employment Information – Beginning with yo ur last employer, l ist all employment (bo th full and pa r t-time) in the past 18

months. If you had more t ha n 2 employers, list the remaining emplo yers on the reverse side of this form in the space provided.

19a. Name and address of your most recent employer:

__________________________________________________

(Street) (City) (State) (Zip)

Period of employment: From _______________ To_____________

month/day/year month/day/year

Wor k

Telephone: ____________________ Location _________________

City State

Occupation: ________________________________ Full time Part time Union _____________ Division___________________

Check the d ays of the week you normally wo rk. SUN MON TUE WED THUR FRI SAT

19b. Name and address:

__________________________________________________

(Street) (Cit y) (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 d ays of the week you normally w o rk . SUN MON TUE WED THUR FRI SAT

20. Other Benefits – You M ust Answer Each Question Li sted Below For the Period of Disability Covered By This Claim:

a. Have you wor ked aft er yo ur di sability began? (I ncludi ng s elf-empl oyment ) Yes No

b. Have you been receiving sick or vacation pay? Yes No

c. Have yo u 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 o r uni on? Yes No

b. Pension benefits from y o ur most recent employer? Yes

No e. Unempl oyme nt I nsurance Be nefit s ? Yes No

c. Temporary Disability Benefits from another State? Yes No

BE SURE TO COMPLETE AND SIGN PART A1

WDS-1 (R-12-14)

Claimant’s Name:_________________________________________

Claimant’s Telephone No: (_____)___________________________

Social Security Number

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PART A1

CLAIMANT’S AUTHORIZATION AND CERTIFICATION STATEMENTS

MUST BE COMPLETED AND SIGNED BY THE CLAIMANT

1. P lease designate a representative to obtain claim information for you if you cannot call this Age nc y yo urself. The Law only permits

claim informatio n to be given to you or your representative.

Representative Name: ___________________________________________________Birth Date:_____________________________

Pho ne (______ )____________________________________

2. Certification and Signature I was unable to work during the period for which benefits are claimed and hereb y certify that I have

read and understand my benefit rights and responsibilities. I a m 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 cri minal prosecutio n. Y ou ar e

hereby authorized to verify my Social Security Account Number, and obtain any medical, employment and Social Security benefit

entitle ment i nformatio n that is nec e ssary to determine m y eligibility for b e nefits.

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 enti ty” under the Federa l H e a lth Information Portab ility &

Accountabilit y Act (HIPAA). All medical records of the Division, except to t he extent necessar y for the proper administration o f the

T emporary Disability Benefits Law are confidential & are not op en to public inspe c tion. The Division protects all record s that ma y

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

th e La w.

USE THIS SPACE TO LIST ADDITIONAL EMPLOYERS FOR QUESTION 19.

Name and address:

__________________________________________________

(Street) (Cit y) (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 d ays of the week you normal ly work . SUN MON TUE WED THUR FRI SAT

Name and address:

__________________________________________________

(Street) (Cit y) (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 d ays of the week you normal ly 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-12-14)

Claimant’s Name: ________________________________________________

Claimant’s Address:_______________________________________________

Claimant ’s Telephone No: (_______)__________________________________

Soc ial Security Num ber

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PART B

MEDICAL CERTIFIC A TE

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

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

(M onth/D ay/Year) (Month/Day/Year)

b. Frequency of treatment: ___________________________________

c. Pa tie nt was last tr e a te d by me on: ____________|___________|_________

Month Day Year

2. Ent e r the date the patie nt was unable to perform his/her regular work due to this disability: _______|___________|_________

M onth Day Year

3. Estimated Recovery: (Give the approximate date patient will be able to return to work.) ____________|___________|_________

Mont h Day Year

4. If now recovered, on what date was the patient first able to work? ____________|___________|_________

M onth Day Ye ar

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: ____________|___________|_________

Mont h Day Year

b. Complications, if any.____________________________________________________

c. If pregnancy terminated , enter the date: ____________|___________|_________

Month Day Year

And i denti fy the reason: Birth C-Section Miscarriage Abortion

7a. Date(s) of emer gency 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 t his disability: Due to an accident at work? No t 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 I f yes, please suppl y the infor mation below if available.

Name of referring doctor ______________________________Referring doctor’s telephone #:____________________

11 . I certify that the above state ments, in my op inion, truly d e scr ibe the p a tie nt’s disability and the estimated duration ther e of:

____________________________________________ _______________________________________ ______________________

(Print Doc tor’s Na m e and Medic al Degree) (Original Signa ture of Doct or Requ ired) (Date Signed)

__________ ____________ ____________ _________ ____________ _____________ _________ ____________ ___________________ If Resident, check

(Address) (Certif icate License No . and S tate)

_______________________________________________________________ ____________________________________________________________________

(Address) (Specialty of Treating Physician)

__________ ____________ ____________ _________ ____________ _______

(Cit y) (Stat e) (Zip Cod e)

Telephone Number: ( )______________________________ FAX Number: ( )_______________________________

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

Clt’s Address:__________________________________________________________________

SOCIAL SECURITY NUMBER

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PART C

TO BE COMP LETED BY YO UR EMP LOYER OR COMPANY REPRESENTATIVE

WDS-1(R-12-14)

2. EMPLOYER STATUS

What is your Federal Employer Identification Number: ___________________

8. B ASE WEEKS AND BASE YEAR GROSS

WAGES A BASE WEEK is a calendar week in

whic h the claimant had New Jerse y earnings of $165

or more OR an y we ek (up to 13 weeks) in which the

claimant is separated fro m employment due to a

declared state of emergency d uring the base year.

The BASE YEAR is the 52 calendar weeks

preceding the week in which the disability occurred.

a. Total Number of Base Weeks _______________

b. Total Gross Wages in Base Year ____________

Include all wages earned by the claimant

9. REGULA R WEEKLY WA GE $_____________

3. PRIVATE PLAN COVE RAG E

(NJ approved plan/replaces State Plan coverage)

a. Do you have a New Jersey ap p r o ved Private Plan? Yes No

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

Yes No

4. LAST ACTUAL DAY WORK ED befor e t his disability

(do not use pay r oll week ending da tes) ______|______|______

(Mont h / Day / Year )

a. Reason for separation from work if other than

disability _____________________________________________________

b. Is lack of work:

temporary? permanent?

c. Has claimant retur ned to work?

Yes No

If “Yes”, give date _______|_____|______

(Month / Day / Year)

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

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

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

of work?

Yes No

b. If “yes” give dates: FROM ______|_____|_____ TO _____|_____|_____

(

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

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

and amounts.

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

1 . Regular we ekly wages and/or sick pay

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

3. Pension

4. Difference between regular weekly wage and disability bene fits to be

received

5. Full salary advanced to effect #4 above

6. Supplemental be nefits or gratuities

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

10. Weekly wages

Indicate below: dates and claimant’s GROSS

ear ni ngs in N.J. employme nt during the l isted

calendar wee ks.

Description o f

Calendar Week

Calendar

Week

Endi ng Date

Gross

Wages

Wee k Disability

Began

Week Before

Disability

2nd Week Before

Disability

3rd Week Before

Disability

4th Week Before

Disability

5th Week Before

Disability

6th

Week Before

Disability

7th Week Before

Disability

8th Week Before

Disability

9th Week Before

Disability

10th Week Before

Disability

TOTAL GROSS WAGES FOR

ABO V E WE EKS

Are you exempt from FI CA tax? Ye s No

6. GOV ERNMENT EMPLOYEES (Complete this section)

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

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

c. Has the claimant filed for or r eceived Emplo yment Disabilit y Leave

(SL I)?

Ye s No

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

amounts on a separate sheet of paper.

7. WORK ERS’ COMPENSATION LIABILITY

a. Did the claimant’s disabilit y happen in con nec tion with h is/her work o r

while on your pr emises, o r was the disa bi lity due in any way to his/her

occupation?

Ye s No

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

claim on behalf of this claiman t?

Ye s No

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

Name______________________________Telephone ( ) _______________

Address__________________________________________________________

Policy #_______________________ Claim #___________________________

11. Chec k the days of the week the employee no r mally wor k s. SUN MON TUE WED THUR FRI SAT

Firm Name __________________________________________I CERTIFY TH E INFORMATION GIVEN ABO VE IS CORRECT

Address ____________________________________________ Signed_____________________________Date___________________

City, State, Zip_______________________________________ Print or Type Name _________________________________________

Mailing Address, If Different____________________________ Official Title_______________________________________________

FAX No. ( ) _______________________ Telephone ( ) _____________________E-Mail Address_______________________