CLAIMANT RIGHTS AND RESPONSIBILITIES RULES FOR FILING

DIVISION OF TEMPORARY DISABILITY INSURANCE

CLAIM FOR DISABILITY BENEFITS (DS-1)

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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

Disability Insurance.

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

benefits, attach 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 Temporar

Disabilit

Insurance

PO Box 387

Trenton, NJ 08625-0387

FAX No: (609) 984-4138

STATE OF NEW JERSEY – DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT

DIVISION OF TEMPORARY DISABILITY INSURANCE

PART A INFORMATION TO BE COMPLETED BY THE CLAIMANT – Print or Type WDS-1(R-12-15)

1. Name: Last First Middle

2. Birth Date

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3.Social Security Number

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4. Home Address – required (Street, Apt #, City, State, Zip Code)

5. County

6. Mailing Address – if different (Street, Apt #, City, State, Zip Code) 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 ___________

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

12b. Reason for separation: Illness/Accident/Maternity Terminated Quit

Month Day Year

13. What was the first day you were unable to work due to present disability:

(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 future)

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

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

16. Describe your disability (How, when, where it happened) _________________________________________________________

________________________________________________________________________________________________________________________________________

17. Was this injury/illness caused by your job? Yes or No (This question must be answered.)

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

Was your employer notified that your injury/illness was a result of a work-related accident? Yes

or No

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

Address: ____________________________________________________________ Telephone: (_____)_________________________

Employment Information – Beginning with your last employer, list all employment (both full and part-time) in the past 18

months. If you had more than 2 employers, list the remaining employers 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

Work

Telephone: ____________________ Location _________________

City State

Occupation: ________________________________ Full time Part time Union _____________ Division___________________

Check the days of the week you normally work. SUN MON TUE WED THUR FRI SAT

19b. Name and address:

__________________________________________________

(Street) (City) (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 days of the week you normally work. SUN MON TUE WED THUR FRI SAT

20. Other Benefits – You Must Answer Each Question Listed Below For the Period of Disability Covered By This Claim:

a. Have you worked after your disability began? (Including self-employment) Yes No

b. Have you been receiving sick or vacation pay? Yes

c. Have you 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 or union? Yes No

b. Pension benefits from your most recent employer? Yes No e. Unemployment Insurance Benefits? Yes No

c. Temporary Disability Benefits from another State? Yes No

BE SURE TO COMPLETE AND SIGN PART A1

WDS-1 (R-12-15)

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. Please designate a representative to obtain claim information for you if you cannot call this Agency yourself. The Law only permits

claim information to be given to you or your representative.

Representative Name: ___________________________________________________Birth Date:_____________________________

Phone (______ )____________________________________

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

read and understand my benefit rights and responsibilities. I am 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 criminal prosecution. You are

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

entitlement information that is necessary to determine my eligibility for benefits.

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 entity” under the Federal Health Information Portability &

Accountability Act (HIPAA). All medical records of the Division, except to the extent necessary for the proper administration of the

Temporary Disability Benefits Law are confidential & are not open to public inspection. The Division protects all records that may

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

the Law.

USE THIS SPACE TO LIST ADDITIONAL EMPLOYERS FOR QUESTION 19.

Name and address:

__________________________________________________

(Street) (City) (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 days of the week you normally work. SUN MON TUE WED THUR FRI SAT

Name and address:

__________________________________________________

(Street) (City) (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 days of the week you normally 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-12-15)

Claimant’s Name: ________________________________________________

Claimant’s Address:_______________________________________________

Claimant’s Telephone No:(_______)__________________________________

Social Security Number

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PART B

MEDICAL CERTIFICATE

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

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

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

b. Frequency of treatment: ___________________________________

c. Patient was last treated by me on: ____________|___________|_________

Month Day Year

2. Enter the date the patient was unable to perform his/her regular work due to this disability: _______|___________|_________

Month Day Year

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

Month Day Year

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

Month Day Year

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: ____________|___________|_________

Month Day Year

b. Complications, if any.____________________________________________________

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

Month Day Year

And identify the reason: Birth C-Section Miscarriage Abortion

7a. Date(s) of emergency 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 this disability: Due to an accident at work? Not 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 If yes, please supply the information below if available.

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

11. I certify that the above statements, in my opinion, truly describe the patient’s disability and the estimated duration thereof:

____________________________________________ _______________________________________ ______________________

(Print Doctor’s Name and Medical Degree) (Original Signature of Doctor Required) (Date Signed)

_______________________________________________________ _____________________________________________________ If Resident, check

(Address) (Certificate License No. and State)

_______________________________________________________________ ____________________________________________________________________

(Address) (Specialty of Treating Physician)

______________________________________________________________

(City) (State) (Zip Code)

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 COMPLETED BY YOUR EMPLOYER OR COMPANY REPRESENTATIVE WDS-1(R-12-15)

2. EMPLOYER STATUS

What is your Federal Employer Identification Number: ___________________

8. BASE WEEKS AND BASE YEAR GROSS

WAGES A BASE WEEK is a calendar week in

which the claimant had New Jersey earnings of $168

or more OR any week (up to 13 weeks) in which the

claimant is separated from employment due to a

declared state of emergency during 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. REGULAR WEEKLY WAGE $____________

(base hours x rate)

3. PRIVATE PLAN COVERAGE (NJ approved plan/replaces State Plan coverage)

a. Do you have a New Jersey approved Private Plan? Yes No

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

Yes No

4. LAST ACTUAL DAY WORKED before this disability

(do not use payroll week ending dates) ______|______|______

(Month / Day / Year)

a. Reason for separation from work if other than

disability _____________________________________________________

b. Is lack of work:

temporary? permanent?

c. Has claimant returned 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 for work prior to disability)

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

of work?

Yes No (Attach sheet for multiple periods)

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. Total amount paid for this period $ ______________

e. Check the number that best describes the monies paid in item c.

1. Regular weekly wages and/or sick pay

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

3. Pension

4. Difference between regular weekly wage and disability benefits to be

received

5. Supplemental benefits or gratuities

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

10. Weekly wages

Indicate below: dates and claimant’s GROSS

earnings in N.J. employment during the listed

calendar weeks.

Description of

Calendar Week

Calendar

Week

Ending Date

Gross

Wages

Week Disability

Began

Week Before

Disability

2nd Week Before

Disability

3rd Week Before

Disability

4th Week Before

Disability

5th Week Before

Disability

6thWeek Before

Disability

7th Week Before

Disability

8th Week Before

Disability

9th Week Before

Disability

10th Week Before

Disability

TOTAL GROSS WAGES FOR

ABOVE WEEKS

Are you exempt from FICA tax? Yes No

6. GOVERNMENT 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 received Employment Disability Leave

(SLI)?

Yes No

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

amounts on a separate sheet of paper.

7. WORKERS’ COMPENSATION LIABILITY

a. Did the claimant’s disability happen in connection with his/her work or

while on your premises, or was the disability due in any way to his/her

occupation?

Yes No

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

claim on behalf of this claimant?

Yes No

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

Name______________________________Telephone ( ) _______________

Address__________________________________________________________

Policy #_______________________ Claim #___________________________

11. Check the days of the week the employee normally works. SUN MON TUE WED THUR FRI SAT

Firm Name __________________________________________I CERTIFY THE INFORMATION GIVEN ABOVE IS CORRECT

Address ____________________________________________ Signed_____________________________Date___________________

City, State, Zip_______________________________________ Print or Type Name _________________________________________

Mailing Address, If Different____________________________ Official Title_______________________________________________

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