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It gathers personal information, home and mailing addresses, phone and county, statistical background questions, disability onset and recovery dates, emergency room or hospitalization dates, physician information, and whether the condition is job-related. 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Box387,Trenton, NJ08625-0387  \nFax:609-984-4138  \nDSDSDS  \n\n| PART A | YOUR INFORMATION | |\n| --- | --- | --- |\n\nInternal Code  \n Social Security Number  \nProfile Information  \n\n| 1 Last name First name Middle |  | 4 Date of Birth\u003Cbr>| |\u003Cbr>______ ______ ______\u003Cbr>mm | dd | yy | 5 Gender |\n| --- | --- | --- | --- |\n| 2 Home Address (Street, Apt \\#, City, State, ZIP Code) |  |  |  |\n|  |  | 6 County |  |\n| 3 Mailing Address–if different from home address (Street, Apt \\#, City, State, ZIP Code) |  |  |  |\n|  |  | 7 Phone (  )   |  |\n| Questions 8 and 9 are for statistical purposes only and do not affect eligibility |  |  |  |\n| 8 With which racial/ethnic group(s) do you most identify?\u003Cbr> Caucasian  Native Hawaiian/Pacific Islander\u003Cbr> African American  American Indian/Alaskan Native\u003Cbr> Asian Latino/Hispanic  Yes  No | 9 Check the highest level of schooling you have completed.\u003Cbr> Have not graduated high school  Associates/Bachelor's Degree  High School Graduate/GED  Graduate Degree |  |  |\n\nDisability Information  \n\n| 10 First date you were unable to work and under medical care for this disability (Include Saturday, Sunday or holiday) | | |\u003Cbr>_______ _______ _______\u003Cbr>mm | dd | yy |\n| --- | --- |\n| 11 Date you recovered or returned to work _______|_______|_______mm | dd | yy |  |\n| 12 Date(s) of emergency room care or hospitalization from   |  |  to   |  | (If dates are provided, attach proof ; e. g. discharge papers) mm | dd | yy mm | dd | yy |  |\n| 13 Describe your disability (for injuries, explain how and where it happened)   |  |\n| 14 Physician's Name   City   State   Phone (  )   |  |\n| 15 Was this injury or illness caused by your job?  Yes  No\u003Cbr>If yes, have you or your employer (s) filed or intend to file a Workers' Compensation claim?  Yes  No |  |\n\nAdditional Benefit Information  \n\n| 16 Do you want federal income tax withheld weekly from your benefits?  Yes  No\u003Cbr>If yes, enter the weekly dollar amount to be withheld (not percentage) $   (amount must be at least $20) |\n| --- |\n| 17 During the period of disability covered by this claim, have you received or applied for:\u003Cbr>a Federal Social Security Disability benefits?  Yes  No If Yes, enter start/application date _______|_______|_______\u003Cbr>b Pension benefits from your current employer?  Yes  No If Yes, enter start date   |   |   Monthly amount $  c Temporary Disability benefits from another state?  Yes  No\u003Cbr>d Unemployment Insurance benefits?  Yes  No |\n\nCertification and Signature  \n\n| 18 I certify I was unable to work during the period for which I am claiming benefits. I am aware that if I provide any information in this application that I know to be false, or if 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 Number, and obtain any medical, employment and Social Security benefit information necessary to determine my eligibility for benefits.\u003Cbr>Sign Here   Date   |  | \u003Cbr>Witness signature if claimant writes an \"X\"   |\n| --- |\n| You may assign a representative to obtain claim information for you if you cannot call us yourself. We can only give claim information to you and your representative.\u003Cbr>19 Approved Representative Name   Date of Birth   |  | \u003Cbr>Representative Phone Number (  ) \u003Cbr>Note: The NJ Temporary Disability Benefits program is not a \"covered entity\" under the Federal Health Information Portability and 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 and 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","cbCaipSc7tj7uXlN","https://ap.wps.com/l/cbCaipSc7tj7uXlN","pdf",1222619,"English","# Part A - Your Information\n## Disability Information\n## Additional Benefit Information\n## Certification and Signature\n# Part B - Employment Information","[{\"question\":\"What personal information is collected in Part A?\",\"answer\":\"Part A collects the claimant’s last name, first name, middle initial, date of birth, gender, internal code, Social Security Number, home and mailing addresses, county, and phone number. It also includes statistical questions about racial/ethnic group and highest completed schooling.\"},{\"question\":\"What disability details are required for eligibility processing?\",\"answer\":\"The form requests the first date the claimant was unable to work and was under medical care, the date of recovery or return to work, and dates of emergency room care or hospitalization. It also asks for a description of the disability and the physician’s name, city, state, and phone number.\"},{\"question\":\"How does the application address other benefits and tax withholding?\",\"answer\":\"It asks whether federal income tax should be withheld weekly from benefits and the weekly amount if applicable. It also lists questions about whether the claimant received or applied for federal Social Security disability benefits, pension benefits, temporary disability benefits from another state, and unemployment insurance benefits.\"}]","DS-1 - New Jersey Temporary Disability Benefits Application - Part 1 | PDF"]