New Jersey > Workers Comp > Misc
Request For Records Inspection WC-147 - New Jersey
| Request For Records Inspection Form. This is a New Jersey form and can be used in Misc Workers Comp . |
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JLltah af ~em 3Jer.ev Department of Labor and Workforce Development Division. of Workers' Compensation POBox 381 Trenton, New Jersey 08625-0381 REQUEST FOR RECORDS INSPECTION Requestor I 0 ~ormaf 100: 1. Your Name: 2. Company Name: 3. Address: (0 Check if new address) 4. Telephone: 5. Your File No: 6. Account No (If previous requestor): DDDDDDD Search Criteria: 1. Petitioner SS # (required): 3. Petitioner Name (required): 4. Records Requested if NOT Entire Case File(s): 2. Claim Petition # (required): o Exclude above CP# from search. o Claim Petition!Answer o Medical o Closure Documents The following statement must be completed, signed, dated and submitted to the ~ivision of Workers' Compensation at the address shown above. All copies of documents provided through this request shall adhere to the provisions ofN.J.S.A. 34:15-128, et seq as shown on the reverse. CERTIFICATION o (Check appropriate box and complete the required information.) I, the undersigned, do hereby certify that I am the claimant, the employer, the insurance carrier or the authorized agent of the claimant, the employer or the insurance carrier and that I am a party to or an authorized agent for a party in a pending workers' compensation case and that use of any records provided through this request will be used solely for purposes directly related to the above requested case. (Copy of agent authorization must be attached.) I, the undersigned, do hereby certify that I am a third party or an authorized agent for a third party directly involved in a workers' compensation case and that any records provided through this request will be used solely for purposes directly related to the above requested case. (Copy of agent authorization must be attached.) I, the undersigned, do hereby certify that I have received specific written release from the claimant in the above requested case allowing me to receive records related to this case, that such written release is attached hereto, and that I have read and agree to the restrictions on my use of such records as prescribed by law. I, the undersigned, do hereby certify that I am an official of a governmental agency and anl authorized to request the above case information for purposes of carrying out the recognized purposes of my agency and shall not subsequently disclose any of such information to any person, organization, entity or governmental agency not entitled to receive such information. I, the undersigned, do hereby certify that I am the employer or the authorized agent for the employer and have obtained a signed authorization for the release of workers' compensation records from the prospective employee. The employer has certified that the employee has received an offer of employment and that the information will be used solely in accordance with the provisions of the Americans With Disabilities Act (ADA) and the New Jersey Law Against Discrimination (LAD). (Copy of agent authorization, original signed employee authorization and original signed employer certification must be attached.) CJ o o Cl Signature: Printed Name: _ _ Date _ Delivery of Copies. Unless otherwise indicated above, copies will be issued to the requestor via first class mail upon completion. P.L.1963,c.73 (C.41: lA-l et seq.) requires that copies of requested documents be made available within seven business days where such documents are currently available and not in storage or archived. Every effort will be made to complete such request and issue resulting copies within seven business days. Where the location or storage condition of requested documents will result in a delay beyond seven business days, the requestor will be notified of such delay and an estimated completion date by first class mail within seven business days of the date of the request. Fees: Copies are certified and are billable at a rate of $.05 per page for each workers' compensation case identified meeting the above search criteria. Billed amounts are due upon presentation. The Division also reserves the right to deny copy services to any requestor where payment for previous copy work remains unpaid for a period of not less than sixty days following delivery and billing for same. A service charge of $25.00 shall also be assessed for any returned payment instrument. WC-147 (R I-II) American LegalNet, Inc. www.FormsWorkFlow.com 34: 15-128 Limited right to inspect, copy records. 1.a. Notwithstanding any other provisions of the chapter to which this act is a supplement or of any other law, no records maintained by the Division of Workers' Compensation or the Compensation Rating and Inspection Bureau shall be disclosed to any person who seeks disclosure of the records for the purpose of selling or furnishing for a consideration to others information from those records or reports or abstracts or workers' compensation records or work-injury records pertaining to any claimant. No information shall be disclosed from those records to any person not in the division unless: (1) The information is provided in a manner which makes it impossible to identify the claimant; (2) The records are opened for the exclusive purpose of permitting a claimant, employer, insurance carrier or authorized agent of the claimant, employer or insurance carrier to conduct an investigation by or on behalf of the claimant, employer or insurance carrier in connection with any pending workers' compensation case to which the clainlant, employer or insurance carrier is a party, and the party seeking access to the records certifies to the division that the information from the records will be used only for the purposes directly related to the case. (3) The records are opened for the exclusive purpose of permitting a third party directly involved in a workers' compensation case, including any workers' compensation lienholders, or an authorized agent of the third party, to conduct an investigation by or on behalf of the third party in' connection with the case, and the party seeking access to the records certifies to the division that the information from the records will be used only for the purposes directly related to the case. (4) The records are subpoenaed by the Commissioner of Banking and Insurance pursuant to section 10 ofP.L.1983,c.320(C.17:33A-10) or by a court of competent jurisdiction in a civil or criminal proceeding. (5) The division provides the information to another government agency pursuant to law, for a duly recognized purpose of that agency, which
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