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Order (Judgment Or Approving Settlement) With Case Exhibit Listing WC(DO)-100 - New Jersey
| Order (Judgment Or Approving Settlement) With Case Exhibit Listing 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(DO)-100 Interactive (r. 4/24/13) NAME: ORDER JUDGMENT APPROVING SETTLEMENT CASE NO'S.: VICINAGE: FEDERAL EMPLOYER NUMBER DATE OF BIRTH: MEDICARE ELIGIBLE: ADDRESS: ATTORNEY FOR PETITIONER PETITIONER NAME: YES NO ADDRESS: vs RESPONDENT NAME: TELEPHONE NUMBER (AREA CODE): APPEARING: ADDRESS: NAME SELF-INSURED TPA INSURANCE CARRIER ADDRESS: NAME: ATTORNEY FOR RESPONDENT ADDRESS: CLAIM NUMBER: DATE OF ACCIDENT OR OCCUPATIONAL EXPOSURE: TELEPHONE NUMBER (AREA CODE): DESCRIBE (Briefly): APPEARING: Weekly Wages : $ Rate(s): $ / $ IF RE-OPENED PETITION, INDICATE FOR LAST AWARD: Date: Permanent Paid: $ Temporary Paid: DAY OF $ , THIS MATTER HAVING COME BEFORE THE COURT ON THIS 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 indicated on Page 2. 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 indicated on page 2. PERMANENT DISABILITY (Describe Percentages below followed by the Nature and Extent of Injury and Members involved): % of American LegalNet, Inc. www.FormsWorkFlow.com State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC(DO)-100 Interactive (r. 4//24/13) ORDER CASE NO'S.: JUDGMENT APPROVING SETTLEMENT VICINAGE: DISABILITY AWARDED: TEMPORARY: PERMANENT: weeks at $ weeks at $ =$ =$ less $ less $ Voluntary Tender paid = Balance due $ paid = Balance due $ Reopener Credit N.J.S.A. 34:15-40 MEDICAL BILLS (Doctors and/or Institutions) AND/OR MISCELLANEOUS INFORMATION: ORDER FOR CHILD SUPPORT ALLOWANCES MEDICAL FEE ALLOWED: (report and/or testimony) ADDENDUM ATTACHED REIMBURSE TAX IDENTIFICATION NUMBER TOTAL AMT. ALLOWED PAYABLE BY PETITIONER PAYABLE BY RESPONDENT INTERPRETER: ATTORNEY(S) FEE: STENOGRAPHIC SERVICE MISCELLANEOUS FEES: (list below) WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY: PETITIONER'S ATTORNEY JUDGE OF COMPENSATION DATE 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. American LegalNet, Inc. www.FormsWorkFlow.com RESPONDENT'S ATTORNEY State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-168 r. 4/24/13 CASE EXHIBIT LISTING FOR: PETITIONER RESPONDENT CASE NO'S.: VICINAGE: Judge: Petitioner: Petitioner Attorney: Hearing Date No. ID Ev. Description Respondent: Respondent Attorney: Retained Court Atty. Reporter Page of American LegalNet, Inc. www.FormsWorkFlow.com
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