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Addendum To Order For Total Disability WC-377 - New Jersey
| Addendum To Order For Total Disability Form. This is a New Jersey form and can be used in Settlement Workers Comp . |
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State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-377(2-08-06) ADDENDUM TO ORDER FOR TOTAL DISABILITY CASE NO'S.: VICINAGE: Case Name: Petitioner's Social Security Number: Petitioner is in receipt of a government ordinary disability retirement pension. The date of retirement was ________________. The initial retirement benefit was $ ______________ per month. The pension portion of the retirement benefit was $ _____________ per month. The annuity portion of the retirement benefit was $ ______________ per month. The respondent and/or the Second Injury Fund is/are entitled to an offset for this benefit. Based upon the last compensable injury and the reasons for the ordinary disability retirement, the offset shall be _________ % of the pension portion of the retirement benefit, or $ ____________ per week resulting in a weekly rate of $ __________________. Other: JUDGE OF COMPENSATION WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY: DATE PETITIONER'S ATTORNEY RESPONDENT'S ATTORNEY PETITIONER (where applicable) DEPUTY ATTORNEY GENERAL American LegalNet, Inc. www.FormsWorkflow.com
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