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    TDI Claim Summary

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    Anonymous UH3ooofwu
    The applicant has submitted a claim for Temporary Disability Insurance benefits with a claim ID of 156913. They must submit required medical forms from their doctor within 14 days for their claim to be eligible. Any requested information on Form C-01 must also be submitted within 14 days. The applicant should notify the office if their circumstances change regarding work, address, wages, or benefits. Eligible benefit payments will be deposited to a debit card. The applicant's disability began on February 6, 2019 and is estimated to last until March 15, 2019.

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    TDI Claim Summary

    Uploaded by

    Anonymous UH3ooofwu
    193 views4 pages
    The applicant has submitted a claim for Temporary Disability Insurance benefits with a claim ID of 156913. They must submit required medical forms from their doctor within 14 days for their claim to be eligible. Any requested information on Form C-01 must also be submitted within 14 days. The applicant should notify the office if their circumstances change regarding work, address, wages, or benefits. Eligible benefit payments will be deposited to a debit card. The applicant's disability began on February 6, 2019 and is estimated to last until March 15, 2019.

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    The applicant has submitted a claim for Temporary Disability Insurance benefits with a claim ID of 156913. They must submit required medical forms from their doctor within 14 days for their claim to be eligible. Any requested information on Form C-01 must also be submitted within 14 days. The applicant should notify the office if their circumstances change regarding work, address, wages, or benefits. Eligible benefit payments will be deposited to a debit card. The applicant's disability began on February 6, 2019 and is estimated to last until March 15, 2019.

    Copyright:

    © All Rights Reserved
    193 views4 pages

    TDI Claim Summary

    Uploaded by

    Anonymous UH3ooofwu
    The applicant has submitted a claim for Temporary Disability Insurance benefits with a claim ID of 156913. They must submit required medical forms from their doctor within 14 days for their claim to be eligible. Any requested information on Form C-01 must also be submitted within 14 days. The applicant should notify the office if their circumstances change regarding work, address, wages, or benefits. Eligible benefit payments will be deposited to a debit card. The applicant's disability began on February 6, 2019 and is estimated to last until March 15, 2019.

    Copyright:

    © All Rights Reserved
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    At a glance
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    The key takeaways from the document are that the claimant needs to submit various forms from their doctor and employer to complete their temporary disability insurance claim, and they will be notified once a decision has been made on their eligibility. They also need to report any changes in circumstances or if they return to work.

    To complete the disability insurance claim, the claimant needs to submit a Request to Claimant form, Employer Statement form, and a Medical Certificate from their doctor. They need to ensure all required information is submitted within 14 days to avoid their claim being determined ineligible.

    Once all the required information is submitted, the claim will be reviewed and the claimant will be notified of a decision on their eligibility for benefits. If approved, benefit payments will be deposited to a debit card. The claimant also needs to notify the office if their circumstances change.

    IMPORTANT INFORMATION AND REMINDERS

    You have successfully submitted your Application for Temporary Disability Insurance benefits. Please make a
    note of your claim identification number listed below:

    Your Claim Identification Number: 156913

    It is your responsibility to print or save the requested forms and submit the instructions to your physician(s) and
    employer(s) to file online.

    If the medical certification is not submitted online by your physcian within fourteen (14) days, your claim will
    be determined ineligible. Your claim will be reviewed upon receipt of the required information.

    If you printed a Request to Claimant for Information Form C-01, additional information must be provided
    within fourteen (14) days. If this requested information is not received within fourteen (14) days, your claim
    will be determined ineligible. Your claim will be reviewed upon receipt of the required information.

    You must notify our office immediately if there is a change for any of the circumstances listed below and it was
    not previously reported to the Division of Temporary Disability Insurance:
    • You return to work or recover from your disability
    • Your mailing address has changed
    • You receive paid time off or wages from your employer
    • You receive a pension from your last employer
    • You receive workers' compensation benefits, Social Security Disability
    benefits or disability benefits from your employer or union
    If you are eligible for benefits, your benefit payments will be deposited to a debit card. Additional information
    pertaining to debit cards can be found on our website at:

    http://lwd.dol.state.nj.us/labor/tdi/content/debit_cards.html

    If you require any assistance with your claim, call:

    Customer Service Section (609) 292-7060.


    Telecommunication Device for the Deaf (TDD) (609) 292-8319
    New Jersey Relay Service: TT user 1-800-852-7899 Voice User: 1-800-852-7897

    Division of Temporary Disability Insurance FAX number: (609) 984-4138

    For additional information about the Temporary Disability Benefits Program, visit our website
    at: http://lwd.dol.state.nj.us/labor/tdi/tdiindex.html

    If your disability is expected to last for one year or longer, you may be eligible for Federal Social Security
    Disability benefits. The toll free number for Social Security is 1-800-772-1213.

    For your convenience a brief summary of the information you have provided on your application has been
    displayed on the following pages.
    2/25/2019
    Temporary Disability Insurance Claim Summary
    Claim Identification Number: 156913

    Claimant Profile
    Name: Murray, Heather A

    Social Security Number: XXX-XX-4930 Date of Birth: 02/12/1973 US Citizen or National: Yes

    Address: 52 WASHINGTON PL
    EAST RUTHERFORD
    NJ 07073

    Occupation: TEACHER ASSISTANT

    Email: Winegirl1717@Yahoo.com

    Primary Phone #: (201)456-4592 Secondary Phone #: (201)456-4592

    Disability Information

    Last Day Worked: 02/05/2019 First Day Disabled: 02/06/2019

    Estimated or Actual Recovery/Return to Work Date: 03/15/2019

    Was your disability work related? No

    Doctor’s Name: James Cahill

    Doctor’s Phone #: (201)489-0022

    Other Benefit Sources

    Temporary Disability Benefits from another State: No

    Social Security Disability Benefits: No

    Disability Benefits from your Employer or Union: No

    Unemployment Insurance Benefits: No

    Withholdings and Late Filing

    Federal Income Tax withholding requested? Yes Amount: $20.00

    Claim filed beyond 30 days from the First Day Disabled? No Explanation Provided?

    Summary - Page 1 of 3
    2/25/2019
    *** The following is a brief summary of the employers that you have provided. Details for your three (3)
    most recent employers are listed. If you have any additional employers only the name of those employers
    will be listed. ***

    Employment Information
    Employer #1: the Meadow School

    Employer’s Phone #: (201)935-2112


    Work Location: Rutherford, NJ
    Last Day Worked: 02/05/2019
    Receiving PTO, Sick, or Vacation Pay: No
    Type:
    Receiving Pension: No
    Working Intermittently During Disability: No Involved in a Labor Dispute: No

    Employer #2: The Meadow School

    Employer’s Phone #: (201)935-2112


    Work Location: Rutherford, NJ
    Last Day Worked: 02/05/2019
    Receiving PTO, Sick, or Vacation Pay: No
    Type:
    Receiving Pension: No
    Working Intermittently During Disability: No Involved in a Labor Dispute: No

    Employer #3:

    Employer’s Phone #:
    Work Location:
    Last Day Worked:
    Receiving PTO, Sick, or Vacation Pay:
    Type:
    Receiving Pension:
    Working Intermittently During Disability: Involved in a Labor Dispute:

    Summary – Page 2 of 3
    2/25/2019
    Additional Employment

    Employer #4:
    Employer #5:
    Employer #6:
    Employer #7:
    Employer #8:
    Employer #9:
    Employer #10:

    Information Requested
    Note: The following information is required to complete your claim. You can print the following forms and
    instructions using the Print Forms Application found at www.nj.gov/labor/PrintFormsApplicationTDI

    Request(s) to Claimant:

    Medical Certificate (M-01) Instructions


    Medical Certificate 19022550058
    Employer Statement(s) (E-01) Instructions
    the Meadow School
    The Meadow School

    Summary - Page 3 of 3
    2/25/2019

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