N.J. Admin. Code § 12:235-7.3 - Certification

(a) Petitioner shall submit a certification when filing a motion for an uninsured claim. The certification shall be specific, and shall contain the following information if known or available to the petitioner and should be supplemented as such information becomes known or available to the petitioner:

1. The date of hire immediately preceding the date of the accident, injury or occupational exposure;

2. The length of employment: If not continuous, list all dates of employment;

3. Copies of petitioner's W-2 forms for all dates of employment during the year in which the accident occurred;

4. Pay stubs for or other documentation in support of all wages received from respondent for the six months immediately preceding the date of the accident or occupational exposure;

5. The total wagers received from respondent for 12 months immediately preceding the accident, which includes salary, gratuities, services, in lieu of wages, meals or lodging;

6. The name, address (business and personal) and phone number of the respondent and any corporate officer or manager of the company;

7. Any documents relating to the employer/employee relationship or lack thereof;

8. A statement of facts which establish the employer-employee relationship;

9. The name, address and phone number of all persons with knowledge of the existence of an employer/employee relationship between petitioner and respondent;

10. The address and/or other identifying information about where the injury occurred, including the name of the owner of the property and the reason why the employee was at the location where the injury occurred;

11. The name, address and phone number of all witnesses to the accident, and whereabouts of respondent when the accident occurred;

12. The name, address and phone number of all persons with any knowledge of the accident;

13. The date on which a medical provider was first contacted concerning injuries sustained in the accident or occupational condition;

14. The name and address of all treating physicians and the name and address of any hospital, laboratory or other facility where treatment was received;

15. Copies of all medical reports from the hospitals and treating physicians;

16. Medical insurance coverage for employee and/or spouse, and if available, the name and address of the company and the policy number;

17. A detailed listing of medical expenses which have been paid, the dates the medical services were provided, the names of individuals and entities providing such services, and the sources and amounts of such payments; and

18. Whether or not the petitioner is receiving or has applied for Social Security, unemployment compensation, temporary disability insurance, disability insurance, pensions or any other wage-related benefits.

Notes

N.J. Admin. Code § 12:235-7.3

Amended by R.1991 d.466, effective 9/3/1991.
See: 23 New Jersey Register 1759(a), 23 New Jersey Register 2642(a).
Petitioner's attorney to advise Fund on benefits received; (b) and (c) deleted.
Recodified from N.J.A.C. 12:235-12.3 by R.2002 d.340, effective 10/21/2002.
See: 34 New Jersey Register 2257(a), 34 New Jersey Register 2549(a), 34 New Jersey Register 3641(d).
Former N.J.A.C. 12:235-7.3, Payment of benefits, recodified to N.J.A.C. 12:235-5.1(e)2 and 12:235-5.2(a) through (c).
Amended by R.2004 d.263, effective 7/6/2004.
See: 36 New Jersey Register 1350(a), 36 New Jersey Register 3294(a).
Rewrote the section.