Department of Labor: WDS1
Department of Labor: WDS1
NOTE: If your disability is expected to last for one year or longer, you may be eligible for Federal Social
Security Disability Benefits.
Toll Free number for Social Security: 1-800-772-1213.
READ THE FOLLOWING INSTRUCTIONS BEFORE COMPLETING THE ATTACHED FORM,
CLAIM FOR DISABILITY BENEFITS – DS-1
1. Complete both sides of the claimant’s portion of this form (Part A & A1.) YOU ARE RESPONSIBLE
for having Part B completed by your doctor and Part C by your last employer. If you have worked for more
than one employer during the past year, you may copy Part C for completion by the other employer(s) to avoid
processing delays. Any missing or incorrect entries on this form will delay processing of your claim. If
you cannot have Parts B and/or C completed timely, complete Part A and A1 and return the application as
soon as possible.
REMEMBER SENDING IN SEPARATE PARTS OF THE APPLICATION
WILL DELAY YOUR CLAIM. NOTE: IF YOU CHOOSE TO FAX THIS
FORM TO OUR OFFICE, BE SURE TO COPY THE BACK SIDE OF EACH
PAGE AND FAX ALL FOUR PAGES AND ANY OTHER ATTACHMENTS.
` MAIL OR FAX PART A, PART A1, PART B AND PART C TOGETHER TO:
Division of Temporary Disability Insurance
PO Box 387
Trenton, NJ 08625-0387
FAX No: (609) 984-4138
2. Read all questions carefully! Print or write clearly since this information is used to determine your right to
benefits. If you need any assistance in completing this form, please call the Customer Service Section in
Trenton at (609) 292-7060 and hold for an agent.
3. BE SURE TO WRITE YOUR SOCIAL SECURITY NUMBER AND NAME ON EACH PORTION OF
YOUR CLAIM.
Instructions For Part A and A1 – Claimant’s Statement – Please complete all questions
Items 1, 4 & 6 Include your full name and complete address (this information is required). If your mailing
address is different than your home address, be sure to complete Item 6.
Please print or type your Social Security Number CLEARLY. An incorrect or illegible
Item 3
number will cause a delay in processing your claim.
Item 9 You must complete this item. If your answer to this question is “No,” you must complete
Items 10 and 11 and give your country of origin.
Items 12 –15 Please give exact dates. Remember to include the dates of any Emergency Room care you
may have received for this disability. If available, provide proof of emergency room care.
List the name and address of the physician who treated you for this disability. You must be
Item 18
under the care of a legally licensed physician, dentist, optometrist, podiatrist, practicing
psychologist, chiropractor or advanced practice nurse. If you have been treated by more
than one physician, use the additional space provided on the reverse side of Part A to list
their names and addresses.
Item 19 Starting with your most recent employer, list all employers, including those for whom you
worked part-time, for the last 18 months. If you had more than two employers, list the
others with the dates you worked in the space provided on Part A1. Give business names
and addresses as they appear on your pay envelopes, pay checks, employers’ stationery or
as listed in the telephone book.
Part A1
In the event that you are unable to telephone our agency, you may designate a
Item 1 representative in this space to obtain information on your behalf. If there is no one listed,
only YOU will be able to obtain information on your claim from this agency.
Item 2 Sign and date the claim form. Include your telephone number.
Important: We suggest that you keep a copy of the completed claim form for your records.
STATE OF NEW JERSEY – DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF TEMPORARY DISABILITY INSURANCE
PART A INFORMATION TO BE COMPLETED BY THE CLAIMANT – Print or Type WDS-1(R-1-07)
6. Mailing Address – if different (Street, Apt #, City State, Zip Code) 7.Male 8. Occupation
Female
9. Are you a citizen of the United States? Yes No 10. Alien Reg. No. 11. Work Authorization
If NO, answer #10 & 11 and give country of origin: ______________ From ___________ To ___________
12a. What was the last day that you actually worked before your disability began? Month Day Year
18. Identify the physician or hospital treating you for this disability: Name: ________________________________________________
2. Certification and Signature I was unable to work during the period for which benefits are claimed and hereby certify that I have
read and understand my benefit rights and responsibilities. I am aware that if any of the foregoing statements made by me are known to
be false, or 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 Account Number, and obtain any medical, employment and Social Security benefit
entitlement information that is necessary to determine my eligibility for benefits.
Note: The NJ Temporary Disability Benefits Program is not a “covered entity” under the Federal Health Information Portability &
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 & 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 Law.
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If more space is needed, attach an additional sheet of paper. Be sure your Social Security Number appears on all pages.
WDS-1(R-1-07)
Claimant’s Name: ________________________________________________
Social Security Number
Claimant’s Address:_______________________________________________ | |
Claimant’s Telephone No:(_______)__________________________________
2. Enter the date the patient was unable to perform his/her regular work due to this disability: _______|___________|_________
Month Day Year
3. Estimated Recovery: (Give the approximate date patient will be able to return to work.) ____________|___________|_________
Month Day Year
4. If now recovered, on what date was the patient first able to work? ____________|___________|_________
Month Day Year
5. Diagnosis: (nature and cause of this disability which prevents patient from working) ______________________________________
_____________________________________________________________________________ ICD Code: _____________________
Clinical data and tests to support diagnosis:__________________________________________________________________________
8. Type of surgery: _______________________ Date of Surgery __________________ Anticipated Surgery Date _________________
10. Was this patient referred to you? Yes No If yes, please supply the information below if available.
Name of referring doctor ______________________________Referring doctor’s telephone #:____________________
11. I certify that the above statements, in my opinion, truly describe the patient’s disability and the estimated duration thereof:
____________________________________________ _______________________________________ ______________________
(Print Doctor’s Name and Medical Degree) (Original Signature of Doctor Required) (Date Signed)
_______________________________________________________________ ____________________________________________________________________
(Address) (Specialty of Treating Physician)
______________________________________________________________
(City) (State) (Zip Code)