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Forms & Publications

The majority of the forms available on our website are available in Adobe Acrobat (PDF) format. Some are also available in Microsoft Word format. To view and print PDF forms, you must have Adobe Acrobat Reader which is a free download from Adobe. Click here to download free software.

A NOTE ABOUT INTERACTIVE FORMS: Many of the forms listed below can be filled out electronically and saved to your local drive. They are denoted by an asterisk and this image: . Please note that interactive Word forms do not convert properly into other word processsing software. Users that do not have Microsoft Word should use the PDF versions of these forms. For further instructions and helpful hints on using interactive forms, click here.

FORMS MENU:

RECENT UPDATES:

Brochures & Publications

Task Force Reports

Employee/Worker Forms

Employer/Insurance Carrier Forms

Litigation Forms
      Petitioner
      Respondent
      Petitioner & Respondent
      Settlement Orders

Schedule of Disabilities
E-Calendars, COURTS on-line and E-Filing
Miscellaneous

4/24/13	Interactive Section 20 Order form (Word &PDF)
4/24/13	Interactive Judgment/Order Approving Settlement form (Word & PDF versions)
4/24/13	Interactive Total Disability Orders (Word & PDF versions)
2/7/13	E-Filing Motions Procedures
1/15/13	WC Rules: Word PDF
1/7/13	Hearing Cycle Calendar

BROCHURES AND PUBLICATIONS		Word	PDF	Misc. Format	Version Date
	Workers' Compensation Statute (Law Book)	Word	PDF		11/19/12
	Workers' Compensation Rules	Word	PDF		1/15/13
	NJ Workers' Compensation Law and Rules Book: This loose leaf publication is available for purchase at a cost of $12.00, which covers postage and handling. The check should be made payable to the NJ Division of Workers' Compensation, P.O. Box 381, Trenton, NJ 08625-0381. Please include your name, mailing address and e-mail address (if available) with the check.
	An Employer's Guide to Workers' Compensation in New Jersey		PDF		7/10
	Injured on the Job? Get the facts about the Informal Hearing Process: (legal size paper)		PDF		6/10
	A Workers' Guide to Workers' Compensation in New Jersey: (legal size paper)		PDF		1/13
	Guia Interpretativa para el Trabajador A la Ley de Compensacion al Trabajador en Nueva Jersey: wc(g)-338s (legal size paper)		PDF		1/13
	Uninsured Employers Fund Pamphlet: scf-122 Provides the regulations associated with the Uninsured Employers Fund (legal size paper)		PDF		11/02
	Second Injury Fund- A Beneficiary's Guide: scf-103 Provides necessary information to recipients of second injury fund benefits. (legal size paper)		PDF		1/11
	Fondo De Segunda Incapacidad - Guia del Beneficiario scf-103s		PDF		1/11
	Task Force and Committee Reports page
	WC Research Manual - link to the instructions page				7/29/11

EMPLOYEE/WORKER FORMS		Word	PDF	Misc. Format	Version Date
	Application for Informal Hearing: WC (CF)-66		PDF		6/06
	Discrimination Complaint Form: SCF-4		PDF		7/04
	* Report of Non-Compliance (interactive): SCF-528 Submit this form to report an uninsured employer		PDF		9/07

EMPLOYER/INSURANCE CARRIER FORMS		Word	PDF	Misc. Format	Version Date
	IA-1 First Report of Injury (FROI): Document maintained by the International Association of Industrial Accident Boards & Commissions (IAIABC).		PDF
	IA-2 Subsequent Report of Injury form (SROI): Document maintained by the International Association of Industrial Accident Boards & Commissions (IAIABC).		PDF
	NJ Benefit Letter - Medical Only: Document maintained at the Compensation Rating and Bureau (NJCRIB) website.		PDF
	NJ Benefit Letter - Indemnity: Document maintained at the Compensation Rating and Bureau (NJCRIB) website.		PDF		10/7/04
	NJ Benefit Letter Usage Directions: Document maintained at the Compensation Rating and Bureau (NJCRIB) website.		PDF		10/7/04
	Employer Notice of Workers' Compensation Insurance Coverage: This link will take you to the NJ Compensation Rating & Inspection Bureau's website.		PDF

FORMAL LITIGATION FORMS		Word	PDF	Misc. Format	Version Date
Petitioner Forms
	Employee's Claim Petition: WC-365		PDF		7/05
	Employee's Claim Petition Supplemental Page: WC-365.1		PDF		7/04
	Application for Review or Modification of Formal Award: WC-368		PDF		7/04
	Dependency Claim Petition: WC-366		PDF		7/04
	* Notice of Motion for Temporary and/or Medical Benefits (Interactive): WC-101_i	Word	PDF		3/07
	Standard petitioner's occupational interrogatory form: WC-22		PDF
	* Second Injury Fund Verified Petition (Interactive): SCF-161_i	Word	PDF		10/10/07
	Social Security Offset Calculation: SCF-16		PDF		5/95
	* Medical Provider Application for Payment or Reimbursement of Medical Payment (Interactive): WC-381	Word	PDF		3/09
	Uninsured Employer's Fund Information Packet		PDF		9/7/07
	Motion for Emergent Medical Treatment		PDF		10/08
	Application for Commutation: WC-60		PDF		6/07
Respondent Forms
	Respondent's Answer to Claim Petition: WC(F)-367		PDF		7/04
	Respondent's Answer to Application for Review & Modification of Formal Award: WC-369		PDF		7/04
	Respondent's Answer to Dependency Claim Petition: WC-171		PDF		7/04
	* Answering Statement for Motion for Medical and/or Temporary Benefits (Interactive): WC-170	Word	PDF		3/07
	Respondent's Answer to Medical Claim Petition		PDF		7/10
	Standard respondent's occupational interrogatory form: WC-23		PDF
Petitioner and Respondent Forms
	Substitution of Attorney: WC10		PDF		8/04
	Subpoena Duces Tecum Ad Testificandum: WC-18		PDF		4/06
	Subpoena Ad Testificandum: WC-18.1		PDF		4/06
	Subpoena Duces Tecum: WC-18.2		PDF		4/06
	Request for Social Security Information: WC-124		PDF		6/04
	Pre-Trial Memorandum: WC-31		PDF		6/07
	* Notice of Motion (Interactive): WC-7	Word	PDF		12/07
	* Trial Scheduling Order (Interactive): WC-16		PDF		6/07
	* Second Injury Fund Information Review Sheet (interactive): WC-380	Word			6/08

SETTLEMENT FORMS		Word	PDF	Misc. Format	Version Date
	* Judgment / Order Approving Settlement (interactive): WC-100i (with Case Exhibit Listing)	Word	PDF		4/13
	* Order for Dismissal (interactive): WC-100Dismissal_i	Word	PDF		3/09
	* Generic Order (for Miscellaneous Decisions, Motions, etc.): (interactive) WC-100Generic	Word	PDF		8/09
	* Order Approving Settlement under NJSA 34:15-20: (interactive) WC-370_i (page 1 and 2)	Word	PDF		4/13
	* Amended Order: (interactive) wc-8		PDF		8/09
	Order for Distribution (for child support): wc103 - wc103.1		PDF		4/06
	Order for Distribution of Temporary Award (for child support): wc379 - wc379.1		PDF		4/06
	Affidavit of Dependent in Support of Settlement Under N.J.S.A. 34:15-20 wc-366.1		PDF		9/9/05
	Medicare Conditional Payment Addendum (Judgment)		PDF		11/10
	Medicare Conditional Payment Addendum (Settlement)		PDF		11/10
	Decision of Dismissal (Second Injury Fund): wc-47		PDF		7/04
	* Order for Total Disability (interactive): wc-374 _i Instructions	Word	PDF		3/2013
	* Order for Total Disability with SS Offset (interactive): wc-375_i Instructions	Word	PDF		3/2013
	* Order for Total Disability with SIF (interactive): wc-376_i Instructions	Word	PDF		3/2013
	Addendum to Order for Total Disability (interactive):* wc-377_i Instructions	Word	PDF		3/2013

SCHEDULES OF DISABILITIES		Word	PDF	Misc. Format	Version Date
	Calendar Year 2002		PDF
	Calendar Year 2003		PDF
	Calendar Year 2004		PDF
	Calendar Year 2005		PDF
	Calendar Year 2006		PDF
	Calendar Year 2007		PDF
	Calendar Year 2008		PDF
	Calendar Year 2009		PDF
	Calendar Year 2010		PDF
	Calendar Year 2011		PDF
	Calendar Year 2012		PDF
	Calendar Year 2013		PDF

ELECTRONIC CALENDARS, COURTS ON-LINE AND ELECTRONIC FILING FORMS		Word	PDF	Misc. Format	Version Date
Electronic Calendars
	* Attorney Calendar E-mail Program application (interactive): This form initiates the transmission of "Attorney Calendar" scheduling notices via e-mail to designated e-mail address(es).	Word	PDF		3/27/09
*COURTS on-line*
	* COURTS on-line Internet Access Application (interactive): This application package needs to be completed if a law firm, insurance carrier or self-insured is interested in accessing COURTS on-line, the Division's on-line case management website. Package contains both the Designation of Contact form and Subscriber application form.	Word	PDF		9/5/12
	*COURTS on-line Subscriber Change Form (interactive): This form needs to be completed if an existing COURTS on-line subscriber has had a change to their name or e-mail address or if their e-filing access level request has changed. The form must be signed by the firm's Contact Person prior to submitting.	Word	PDF		9/6/12
Electronic Filing
	E-Filing Procedures Guide		PDF		6/26/12
	E-Filing Motions Procedures Guide		PDF		2/7/13

MISCELLANEOUS FORMS		Word	PDF	Misc. Format	Version Date
	Uninsured Employer's Fund Information Packet		PDF		9/7/07
	Request for Records Inspection: WC-147 This form must be completed and signed before the Division can release records. (legal size paper)		PDF		7/04
	* Report of Non-Compliance (interactive): SCF-528 This form may be used by any individual or organization to report allegations of failure on the part of an employer to maintain workers' compensation insurance coverage or obtaining authorization to self-insure.		PDF		9/07
	* Insurance Carrier Contact form (interactive): This form to designate a contact person must be completed by every insurance carriers and self-insurer authorized to do business in NJ.		PDF		11/2/09
	Insurance Carrier/ Self-Insurer Contact Listing: These individuals can be contacted by judicial staff and attorneys where there has been no appearance or formal response made by the carrier or their counsel on pending Motions for Medical and Temporary Benefits.		PDF		9/10/12
	Public Sector Contact Listing: Similar to above listing.		PDF		9/10/12
	Hearing Cycle Calendar		PDF		1/7/13