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4.9 out of 5

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The document outlines the process for filing a claim for disability benefits through the New Jersey Division of Temporary Disability Insurance. It details the claimant's rights and responsibilities, including timely filing requirements, appeal procedures, and necessary documentation. The form requires information from both the claimant and their employer, as well as medical certification from a physician. Claimants are advised to keep copies of their submissions and to notify the agency of any changes in address or work status.

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Click ‘Get Form’ to open the Claim for Disability Benefits (DS-1) in the editor.
Begin by completing Part A. Fill in your full name, address, and Social Security Number clearly. Ensure all required fields are filled accurately to avoid delays.
In Item 12, provide the last day you worked before your disability began. Include any emergency room care dates in Items 14 and 15.
Complete Part A1 by listing your physician's details and signing the authorization. This section is crucial for verifying your medical condition.
Ensure Parts B and C are completed by your doctor and employer respectively. If you have multiple employers, make copies of Part C as needed.
Review all entries for accuracy before submitting. Use our platform’s features to save a copy of your completed form for your records.

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Versions	Form popularity	Fillable & printable
2011	4.9 Satisfied (523 Votes)

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