Forms & Publications

The majority of the forms available on our website are available in Adobe Acrobat acrobat image (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: interactive. 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
7/29/11 WC Research Manual acrobat image 
6/6/11 Insurance Carrier Contact listing acrobat image
Public Contact listing acrobat image
4/18/11 WC Rules acrobat image
10/18/10 Hearing Cycle Calendar
7/7/10 Respondent's Answer to Medical CP 

 

BROCHURES AND PUBLICATIONS  

Word  PDF
acrobat		 Misc. Format Version
Date 
Workers' Compensation Statute (Law Book) Word PDF 1/17/10
Workers' Compensation Rules

Word

 PDF 4/18/11
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   1/11
Guia Interpretativa para el Trabajador A la Ley de Compensacion al Trabajador en Nueva Jersey: wc(g)-338s  (legal size paper)   PDF   1/11
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
acrobat		 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
interactive		   9/07
EMPLOYER/INSURANCE CARRIER FORMS   Word  PDF
acrobat		 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
acrobat		 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
interactive		 PDF
interactive		   3/07
Standard petitioner's occupational interrogatory form:  WC-22   PDF    
* Second Injury Fund Verified Petition (Interactive):   SCF-161_i Word
interactive 		 PDF
interactive		   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
interactive		 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
interactive		 PDF
interactive		   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
interactive 		 PDF
interactive		 12/07
* Trial Scheduling Order (Interactive): WC-16 PDF
interactive		 6/07
* Second Injury Fund Information Review Sheet (interactive): WC-380 Word
interactive		 6/08
SETTLEMENT FORMS  Word  PDF
acrobat		 Misc. Format Version
Date 
* Judgment / Order Approving Settlement (interactive):   WC-100i (with Case Exhibit Listing) Word
interactive		 PDF
interactive		   8/09
* Order for Dismissal (interactive):   WC-100Dismissal_i Word
interactive		 PDF
interactive		   3/09
* Generic Order (for Miscellaneous Decisions, Motions, etc.): (interactive) WC-100Generic Word
interactive		 PDF
interactive		 8/09
* Order Approving Settlement under NJSA 34:15-20:  (interactive) WC-370_i (page 1 and 2) Word
interactive		 PDF
interactive		   8/09
* Amended Order:  (interactive) wc-8   PDF
interactive		   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
interactive		 PDF
interactive		   8/09
* Order for Total Disability with SS Offset (interactive):   wc-375_i   Instructions Word
interactive		 PDF
interactive		   8/09
* Order for Total Disability with SIF (interactive):   wc-376_i     Instructions Word
interactive		 PDF
interactive		   8/09
*Addendum to Order for Total Disability (interactive):   wc-377_i   Instructions Word
interactive		 PDF
interactive		   8/09
SCHEDULES OF DISABILITIES  Word  PDF
acrobat		 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 

  

ELECTRONIC CALENDARS, COURTS ON-LINE AND ELECTRONIC FILING FORMS 

Word PDF
acrobat		 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
interactive		 PDF
interactive		   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
interactive		 PDF
interactive		  

6/2009
*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
interactive		 PDF
interactive		   8/7/07 
COURTS on-line FAQ's   PDF   7/2009
COURTS on-line Proceedings Codes    PDF   3/29/05
Electronic Filing
E-Filing Procedures Guide PDF   7/16/09
E-Filing FAQ's PDF   11/10/09
E-Filing Helpful Hints - memo1 Word PDF   8/15/03
E-Filing Helpful Hints - memo2 Word PDF   3/1/04

MISCELLANEOUS FORMS  

 Word  PDF
acrobat		 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
interactive		   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
interactive		   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   5/31/11
Public Sector Contact Listing:
Similar to above listing.		   PDF   5/31/11
Hearing Cycle Calendar   PDF   10/14/11