Free PDF - New Jersey

NEW JERSEY BENEFIT STATUS LETTER ­ Medical Only
[Claim Administrator Letterhead] [Claim Administrator Address]

Date of notice:

To:

[NAME OF INJURED EMPLOYEE] [ADDRESS] [CITY, STATE, ZIP] Date of Injury: Insurance Claim #: Agency Claim #:

Dear [Injured Worker Name], I am handling your claim for workers' compensation benefits. In accordance with [Jurisdiction {New Jersey}] law, I am sending you a summary of your claim and benefits paid to date. The information contained in this notice has already been provided to the state in an electronic format. According to our records, your injury occurred while you were working for: Name of Employer: Employer's Address: Your claim has been accepted as a "medical only" claim. ****If there is a value of 350,360 or 370 in DN95 , insert this paragraph and Benefit section: To date, we have paid the following benefits in relation to your work related injury: Benefit Description _________________________ _________________________ Paid to Date ___________________ ___________________

If you do not agree with the information contained in this letter or if you have any questions, please contact me via one of the methods below: Adjuster's Name: Telephone #: Fax #: E-Mail Address:

Or you may write to the NJ Division of Workers' Compensation at PO Box 381, Trenton, NJ 08625-038, attn: EDI Coordinator. A copy of your letter must be sent to the insurance carrier.

NJ Benefit Status Letter Medical Only 10-07-04.doc

(this text is in white so it will not print)

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