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Free Nj Temporary Disability PDF Template

The New Jersey Temporary Disability Form, known as Form DS-1, serves as a crucial document for individuals who find themselves unable to work due to disability. It outlines the procedure for filing a claim for disability benefits, emphasizing the importance of a timely submission - specifically within 30 days from the onset of disability - to avoid denial or reduction in benefits. The form also guides claimants through their rights, responsibilities, and the appeal process should they disagree with the determination of their claim.

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Free Nj Temporary Disability PDF Template

Outline

The New Jersey Temporary Disability Benefits Program offers critical support to individuals unable to work due to a medical condition, ensuring they have a financial safety net during such challenging times. Through the designated form, officially referred to as the "Claim for Disability Benefits (DS-1)," applicants are guided through a process that encompasses several important steps and requirements. Key aspects of this form include a stern reminder of the responsibility to file promptly after the cessation of work due to a disability, emphasizing that failure to do so within the prescribed 30-day period could result in denied or reduced benefits. Additionally, the form outlines the claimant's responsibilities, such as the need to report any other forms of income, the requirement to submit continued medical certification if requested, and the importance of notifying the Division of any changes in address or employment status. Furthermore, it provides guidance on how to appeal should there be disagreement with a determination, indicating that legal representation is not necessary for such proceedings. For those navigating through the complexities of filing a claim, the document assures assistance is available through various channels, thereby ensuring claimants are supported throughout the process. It is also designed with the anticipation of common queries, thereby containing instructions on completing each section, details regarding eligibility for federal benefits in the case of long-term disabilities, and the necessary steps to designate someone to receive information on the claimant’s behalf, epitomizing a comprehensive guide tailored to streamline the application process for temporary disability benefits in New Jersey.

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DIVISION OF TEMPORARY DISABILITY INSURANCE

CLAIM FOR DISABILITY BENEFITS (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 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.

Please print or type your Social Security Number CLEARLY. An incorrect or illegible number will cause a delay in processing your claim.

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.

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.

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 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.

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.

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.

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.

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 Insurance PO Box 387

Trenton, NJ 08625-0387

FAX No: (609) 984-4138

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

Item 3

Item 9

Items 12 –15

Item 18

Item 19

Part A1

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

Item 1 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.

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-3-11)

1. Name: Last	First	Middle	2. Birth Date
1. Name: Last	First	Middle	2. Birth Date
			\|	\|

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

3.Social Security Number

| |

5. County

6. Mailing Address – if different (Street, Apt #, City, State, Zip Code)							7.Male		8. Occupation
							Female

9. Are you a citizen of the United States? Yes		No		10. Alien Reg. No.		11. Work Authorization
If NO, answer #10 & 11 and give country of origin: ______________						From ___________ To ___________
						From ___________ To ___________
12a. What was the last day that you actually worked before your disability began?						Month		Day		Year
12b. Reason for separation:	Illness/Accident/Maternity		Terminated		Quit
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/YearMonth/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
If Yes, date of work related injury/illness:_________________
Was your employer notified that your injury was caused by your job?			Yes

(This question must be answered.)

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:			Period of employment: From _______________ To_____________
__________________________________________________			Period of employment: From _______________ To_____________
__________________________________________________			month/day/year	month/day/year
			month/day/year	month/day/year
__________________________________________________			Work
__________________________________________________			Telephone: ____________________ Location _________________
(Street)	(City)	(State) (Zip)	City	State
			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	No
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-3-11)

Claimant’s Name:_________________________________________

Claimant’s Telephone No: (_____)___________________________

Social Security Number

| |

	PART A1	CLAIMANT’S AUTHORIZATION AND CERTIFICATION STATEMENTS
	PART A1	MUST BE COMPLETED AND SIGNED BY THE CLAIMANT
		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-3-11)

Claimant’s Name: ________________________________________________

Claimant’s Address:_______________________________________________

Claimant’s Telephone No:(_______)__________________________________

Social Security Number

| |

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

| |

PART C

TO BE COMPLETED BY YOUR EMPLOYER OR COMPANY REPRESENTATIVE

WDS-1(R-3-11)

2. EMPLOYER STATUS

8. BASE WEEKS AND BASE YEAR GROSS

What is your Federal Employer Identification Number: ___________________

WAGES A BASE WEEK is a calendar week in

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

which the claimant had New Jersey earnings of $145

a. Do you have a New Jersey approved Private Plan?

Yes

or more during the Base Year. The BASE YEAR is

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

Yes

the 52 calendar weeks preceding the week in which

4. LAST ACTUAL DAY WORKED before this disability

the disability occurred.

(do not use payroll week ending dates)

______|______|______

(Month

Day

Year)

a. Total Number of Base Weeks _______________

a. Reason for separation from work if other than

disability _____________________________________________________

b. Total Gross Wages in Base Year ____________

b. Is lack of work:

temporary?

permanent?

Include all wages earned by the claimant

c. Has claimant returned to work?

Yes

__________________________________________

If “Yes”, give date

_______|_____|______

(Month

Day

/ Year)

9. REGULAR WEEKLY WAGE $_____________

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

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

10. Weekly wages

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

Indicate below: dates and claimant’s GROSS

of work?

Yes

earnings in N.J. employment during the listed

b. If “yes” give dates:

FROM ______|_____|_____ TO _____|_____|_____

calendar weeks.

(Month /

Day /

Year)

(Month / Day / Year)

Description of

Calendar

Gross

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

Calendar Week

Week

Wages

and amounts.

Ending Date

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

Week Disability

1. Regular weekly wages and/or sick pay

Began

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

Week Before

3. Pension

Disability

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

2nd Week Before

received

Disability

5. Full salary advanced to effect #4 above

3rd Week Before

6. Supplemental benefits or gratuities

Disability

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

4th Week Before

6. GOVERNMENT EMPLOYEES (Complete this section)

Disability

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

5th Week Before

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

Disability

c. Has the claimant filed for or received Employment Disability Leave

6th Week Before

(SLI)?

Yes

Disability

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

7th Week Before

amounts on a separate sheet of paper.

Disability

7. WORKERS’ COMPENSATION LIABILITY

8th Week Before

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

Disability

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

9th Week Before

occupation?

Yes

Disability

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

claim on behalf of this claimant?

Yes

10th Week Before

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

Disability

Name______________________________Telephone (

) _______________

TOTAL GROSS WAGES FOR

Address__________________________________________________________

ABOVE WEEKS

Policy #_______________________ Claim #___________________________

Are you exempt from FICA tax?

Yes

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_______________________

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Document Attributes

Fact Name	Description
Claim Filing Responsibility	It's the claimant's responsibility to file the claim form promptly after stopping work due to disability. The law requires filing within 30 days of disability onset.
Appeal Process	If the claimant disagrees with the decision, an appeal can be filed in writing within ten days from the decision date.
Claimant Certification	By signing, claimants certify their understanding of the responsibilities and acknowledge that misrepresentation or failure to disclose material facts is punishable under the law.
Reporting Other Payments	Claimants must report receiving any other payments like sick pay, pensions, worker's compensation, or Social Security Disability benefits.
Medical Certification Requirement	Upon request for continued medical certification (Form P30), the claimant's physician must complete, sign, and return it promptly.
Reporting Recovery or Return to Work	Claimants must report their recovery or return to work date immediately to the Division of Temporary Disability Insurance.
Voluntary F.I.T. Deductions	For voluntary Federal Income Tax deductions from benefits, attach Form W-4S to the claim.
Updating Contact Information	If home or mailing addresses change, the Division must be notified immediately in writing.
Claim Assistance	For assistance, claimants can contact the Customer Service Section, use TDD equipment, or the New Jersey Relay Service.
Governing Laws	The New Jersey Temporary Disability Benefits Law governs the claim process and requirements.

How to Fill Out Nj Temporary Disability

Filling out the New Jersey Temporary Disability Benefits form is a critical step in ensuring you receive the benefits you're entitled to during your period of disability. Before you start, please make sure you have all the necessary information at hand. This includes your social security number, the dates and details of your employment over the last 18 months, medical information related to your disability, and any other benefits you may be receiving. Accurately completing this form will help avoid delays in the processing of your claim.

Begin by filling in your personal information in Part A, including your name, date of birth, home and mailing addresses, social security number, and contact details.
In response to the question of U.S. citizenship in item 9, if you answer "No," be sure to complete items 10 and 11, detailing your alien registration number, work authorization, and country of origin.
Detail the last day you worked before your disability began, the reason for leaving (illness, accident, maternity, terminated, or quit), and the first day you were unable to work due to your disability in items 12 and 13.
If applicable, include the date of your return to work or recovery from this disability in item 14.
List dates of emergency room care or hospitalization related to your disability in item 15, including the describing nature, occurrence, and cause of your disability in item 16.
Answer whether the injury or illness was caused by your job in item 17 and provide the treating physician or hospital details in item 18.
Fill in your employment information for the last 18 months in section 19, including details for your most recent employer and any additional employers on the reverse side of the form.
Answer the questions regarding other benefits you may have applied for or received during your disability in item 20.
In Part A1, designate a representative if you're unable to call the agency yourself in item 1 and complete the certification and signature section in item 2, including your telephone number and the date.
For Part B, you need to have your doctor complete the Medical Certificate after you become disabled. Ensure they detail the period and nature of your disability, treatment dates, and the estimated recovery or return-to-work date.
If you're requesting voluntary Federal Income Tax deductions from your disability benefits, attach Form W-4S to your claim.
Before mailing or faxing, double-check that all parts of your form (Part A, A1, and Part B) are correctly filled and signed. Both sides of each page, as well as any additional documents, need to be included in your submission.
Mail or fax the completed form and any attachments to the Division of Temporary Disability Insurance at the address or fax number provided in the instructions.

After submitting your claim, allow fourteen days for processing before following up. If you encounter any issues or need assistance, the customer service section is available to help. Remember, accurate and prompt submission of your form and supporting documents is essential in facilitating your claim's approval.

More About Nj Temporary Disability

How do I file a claim for New Jersey Temporary Disability Benefits?

To file a claim for New Jersey Temporary Disability Benefits, after you stop working due to your disability, promptly complete the Claim for Disability Benefits form (DS-1). Ensure both the claimant's portion (Part A & A1) and the sections to be completed by your doctor (Part B) and your last employer (Part C) are fully completed. If you've worked for more than one employer in the past year, make copies of Part C for each employer to fill. Mail or fax all portions together to the Division of Temporary Disability Insurance to avoid processing delays. Remember, separate submissions can slow down the process.
When should I file my claim?

You should file your claim form urgently after your disability causes you to stop working. To prevent any delays in the processing of your claim, do not file before your last working day. The law mandates that claims be filed within 30 days following the start of your disability. Late filings could result in denied or reduced benefits. If you file late, explain your reasons on the back of Part A.
What happens if I disagree with a decision on my claim?

If you disagree with the determination made on your claim, you can appeal in writing within ten days from the date the decision was mailed out. You don't need a lawyer for the appeal hearing. It's your right to challenge decisions you believe are incorrect, and this process is in place to ensure fair review and resolution of disputes.
What are my responsibilities after filing the claim?
- Report any changes, such as recovery or returning to work, immediately to the Division of Temporary Disability Insurance.
- Notify the division if you are receiving other payments like sick pay, pension, worker’s compensation, Social Security Disability, or any other disability benefits.
- If requested, provide continued medical certification.
- Inform the division promptly of any address changes.
- Request voluntary Federal Income Tax withholding by attaching Form W-4S, if desired.
Can I have someone else obtain information about my claim on my behalf?

Yes, you can designate a representative to obtain information about your claim if you are unable to contact the agency yourself. This must be done by listing the representative's name on the claim form. Without a designated individual, information will be shared only with you, ensuring your privacy is protected.
What if I need help or have more questions about my claim?

If you require assistance with your claim or have additional questions, you can contact the Customer Service Section at (609) 292-7060. For hearing-impaired assistance, dial (609) 292-8319 or use the New Jersey Relay Service. Remember to allow up to fourteen days of processing time before inquiring about the status of your claim.

Common mistakes

Filling out the form before stopping work: Some individuals submit their forms before their last workday, not realizing this can delay the process. The claim should be filed promptly after stopping work due to disability.
Missing the 30-day filing window: It's crucial to file the claim within 30 days after the disability begins. Filing late can lead to denied or reduced benefits.
Not providing reasons for late filing: If the claim is submitted after the 30-day period, not explaining the reasons for the delay on the back of Part A can be a significant oversight.
Neglecting to appeal decisions in time: If there's disagreement with a decision, failing to appeal within ten days from the decision date can forfeit the opportunity to contest the determination.
Omitting other payments information: Not disclosing other income sources such as sick pay or worker's compensation can affect the benefits or lead to legal issues.
Forgetting to submit continued medical certification: When requested, not having the form completed by a physician and returning it promptly can interrupt benefits.
Failure to report recovery or work resumption: Not immediately informing the Division when recovering or returning to work can result in overpayment and potential penalties.
Incorrectly completing the tax withholding request: Attaching incorrectly filled out Form W-4S or forgetting it altogether can cause tax withholding issues.
Not updating contact information: Failing to notify the Division of Temporary Disability Insurance about any address changes can delay communication and processing of claims.
Illegible or incorrect Social Security Number (SSN): Writing the SSN unclearly or incorrectly on the form can cause significant delays in claim processing.

Remember: Accuracy, clarity, and timeliness are key when completing your claim form to ensure the prompt and correct processing of your benefits.
Ensure all information relates accurately to your situation, including all dates and details of any medical treatments related to your disability.
Always review your completed form for any omissions or errors before submission to avoid unnecessary delays or complications with your claim.

Documents used along the form

When managing the complexities of filing a New Jersey Temporary Disability Claim, it's essential to understand the other forms and documents often required to support your application. These documents play a critical role in validating your claim and expediting the process. Below is a list of six additional forms or documents frequently used alongside the New Jersey Temporary Disability form:

Medical Certificate (Part B of the DS-1 form): This certificate must be completed by your doctor after you become disabled. It provides detailed information about your medical condition, including diagnosis, the period of disability, treatment frequency, and expected recovery date.
Employer's Statement (Part C of the DS-1 form): This statement is to be completed by your last employer. It details your employment status, wages, and the last day worked before the onset of disability.
W-4S Form: Request for Federal Income Tax Withholding from Sick Pay. If you wish to have federal taxes withheld from your disability benefits, this form must be completed and attached to your claim.
Form P30: Request for Continued Medical Certification. This form is necessary if there is a request for continuous proof of your medical condition throughout your claim period.
Direct Deposit Form: This form is used if you prefer to have your disability benefits deposited directly into your bank account, ensuring faster and more secure access to funds.
Appeal Form: If your claim is denied or you disagree with the decision made regarding your benefits, an appeal form must be completed within the stipulated time frame to contest the decision.

Comprehensive understanding and proper completion of these forms and documents, in conjunction with the New Jersey Temporary Disability form, can significantly influence the outcome of your claim. Each form plays a vital part in sharing precise information about your work history, income, medical condition, and treatment, ensuring a smooth and efficient processing of your temporary disability benefits claim. Thus, attention to detail and adherence to the required guidelines when completing these documents cannot be overstated.

Similar forms

The New Jersey Family Leave Insurance (FLI) claim form is similar in that it also requires personal, employment, and medical information to process a claim for benefits related to family leave, mirroring the need for detailed employment and health information found in the Temporary Disability form.
Workers' Compensation claim forms in New Jersey share similarities, as they require detailed information about the claimant's employment, the nature of the injury or illness, and treatment received, similar to the extensive information required by the Temporary Disability form.
The Social Security Disability Insurance (SSDI) application also gathers comprehensive personal, medical, and employment history to establish eligibility for disability benefits, akin to the requirements of the Temporary Disability form.
Unemployment Insurance (UI) claim forms require claimants to provide personal details, employment history, and reasons for unemployment, reflecting the documentation of employment history and reasons for disability or inability to work as seen in the Temporary Disability form.
State Disability Insurance (SDI) claim forms in states like California ask for personal, medical, and employment information to assess claims, similarly to New Jersey's approach with the Temporary Disability form.
The Federal Employees' Compensation Act (FECA) claim form for federal employees parallels the need for detailed injury, medical treatment, and employment information, akin to the extensive requirements of the Temporary Disability form.
Private disability insurance claim forms often require comprehensive documentation of the claimant's medical condition, the impact on their employment, and a certification by healthcare providers, which is similar to the structure and requirements of the Temporary Disability form.
The Employee's Report of Injury Form for on-the-job injuries mandates detailed reporting of the incident, medical diagnosis, and subsequent treatments, reflecting the similar comprehensive approach for documenting medical care and employment impact in the Temporary Disability form.

Dos and Don'ts

When completing the New Jersey Temporary Disability form, taking the right steps can ensure a smoother process and prevent unnecessary delays. Below are key do's and don'ts to consider:

Do:

Read all instructions carefully before starting the form. This ensures that you understand what information is required and how to provide it correctly.
Print or type clearly in all sections of the form. Legibility is crucial to avoid misunderstandings or processing delays due to illegible handwriting.
Ensure all parts of the form are completed, including the claimant’s portion (Part A & A1), the medical certificate (Part B), and the employer’s statement (Part C). Missing information can lead to processing delays.
Sign and date the form. An unsigned form is considered incomplete and cannot be processed.
Keep a copy of the completed form and any correspondence for your records. This is important for future reference or if any disputes arise.

Don't:

Delay in filing the claim after you stop working due to your disability. Late filing can lead to denied or reduced benefits.
Omit information about other payments you are receiving, such as sick pay, workman’s compensation, or other disability benefits. This information is necessary to determine your eligibility and benefit amount.
Make changes to the Medical Certificate or the Employer’s Statement without proper authorization from your physician or employer. Unauthorized changes can be penalized.
Forget to update your address if you move. Failing to notify the Division of Temporary Disability Insurance in New Jersey about a change of address can lead to delays in receiving benefits or correspondence.
Fail to report when you recover or return to work. Notifying the Division immediately is crucial for accurate benefit determination.

Approaching the process with diligence and attention to detail can help ensure that your claim is filed correctly and processed efficiently, minimizing potential stress during a challenging time.

Misconceptions

When it comes to filing a New Jersey Temporary Disability Claim, many individuals encounter confusion and misunderstanding. To help clarify the process, here are nine common misconceptions about the NJ Temporary Disability form:

All disabilities are covered: Not all conditions qualify for temporary disability benefits. The disability must prevent you from working, and it must be verified by a healthcare provider.
Filing for disability is only for long-term situations: The NJ Temporary Disability program is designed specifically for short-term disabilities. If your disability is expected to last for a year or more, Social Security Disability Benefits may be more appropriate.
You must wait until after your last day of work to file: You are encouraged to file the claim form promptly after stopping work due to your disability. Waiting until after your last day can unnecessarily delay the processing of your claim.
Filing late means automatic denial: While benefits may be reduced or denied if the claim is filed late, it’s possible to provide a reason for the delay. Filing beyond the 30-day period doesn't always result in automatic denial.
You need a lawyer to file an appeal: If you disagree with a decision on your claim, you can file an appeal on your own without the need for a lawyer.
The claim form is the only necessary document: Along with the claim form, medical certification from your doctor and information from your employer are also required to process the claim.
Once you file, there’s no need to provide updates: You must inform the Division of Temporary Disability Insurance about any changes in your condition or work status. Additionally, you must report any other benefits you're receiving.
Your mailing address doesn’t affect your claim: If your mailing or home address changes, you must inform the Division immediately. An incorrect or outdated address can delay the processing of your claim.
Voluntary Federal Income Tax deductions are automatically withheld: If you want Federal Income Tax (F.I.T.) deductions withheld from your disability benefits, you must specifically request this by attaching Form W-4S to your claim.

Understanding these aspects of the NJ Temporary Disability form can help ensure a smoother process and avoid unnecessary delays or issues in receiving benefits.

Key takeaways

Understanding the NJ Temporary Disability Form is crucial for ensuring timely and accurate processing of your claim. Here are key takeaways for applicants:

Timely Filing: The form should be filed promptly after you stop working due to disability. Filing before your last day may delay processing. Claims must be filed within 30 days from the start of the disability to avoid denial or reduction of benefits.
Accuracy and Honesty: It's important to fill out the form accurately and honestly. Any attempt to misrepresent information or fail to disclose important facts, such as other payments being received, can be punishable by law. This includes making unauthorized changes to the medical certificate or the employer's statement.
Medical Certification: Continued medical certification may be requested and must be completed by your physician. Prompt submission of these forms helps in the swift processing of your claim.
Update Personal Information: Inform the Division of Temporary Disability Insurance of any changes in your home and/or mailing address immediately in writing. Include your Social Security Number and signature for verification.
Appealing a Decision: If you disagree with a decision made on your claim, you have the right to appeal in writing within ten days from the date the decision was mailed. You do not need a lawyer for the appeal hearing.

Additional assistance is available through the Customer Service Section for claimants needing help with their forms. All questions must be read carefully and answered fully to determine eligibility for benefits.

Remember, the NJ Temporary Disability Benefits Program aims to provide temporary financial support during times you cannot work due to a disability. Taking the time to carefully and accurately complete and submit all parts of the application, including any medical or employment documentation, is essential for the efficient processing of your claim.

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