Get the free Second Injury Fund - State of NJ
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State of New Jersey
Department of Labor and Workforce Development
DIVISION OF WORKERS COMPENSATION
WC376i (r. 3/19/13)
DOB:SURNAME:
GENDER:MEDICARE ELIGIBLE:YES MALE
FEMALE
ADDRESS (Including County):FEDERAL
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How to fill out second injury fund
How to fill out second injury fund:
01
Gather all necessary documentation such as medical records, accident reports, and any other relevant paperwork.
02
Review the eligibility requirements for the second injury fund to ensure that you meet all necessary criteria.
03
Complete the application form, providing accurate and detailed information about the injured party, the nature of their injury, and any previous disabilities or injuries.
04
Attach all supporting documentation to the application, ensuring that everything is organized and clearly labeled.
05
Double-check the application for any errors or missing information, making sure everything is accurate and complete.
06
Submit the application and supporting documents either electronically or by mail, following the instructions provided by the second injury fund.
Who needs second injury fund:
01
Employees who have suffered a work-related injury or disability and have a pre-existing condition or impairment.
02
Employers who have hired individuals with pre-existing disabilities or injuries.
03
Insurance companies or third-party administrators who may need to access the second injury fund to cover the expenses related to these cases.
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What is second injury fund?
The second injury fund is a state-run program that provides financial assistance to employers who hire individuals with pre-existing disabilities or injuries.
Who is required to file second injury fund?
Employers who hire individuals with pre-existing disabilities or injuries are required to file for second injury fund.
How to fill out second injury fund?
Employers can fill out the second injury fund forms provided by their state's workers' compensation board or department.
What is the purpose of second injury fund?
The purpose of the second injury fund is to encourage employers to hire individuals with pre-existing disabilities or injuries by providing financial support for any additional costs or risks associated with their employment.
What information must be reported on second injury fund?
Employers must report the details of the employee's pre-existing disability or injury, the additional costs or risks associated with their employment, and any accommodations or modifications made to support the employee.
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