Employee Claim Petition Supplemental Page {WC-365.1}

State of New Jersey Department of Labor and Workforce Development Division of Workers' Compensation PO Box 381 Trenton, New Jersey 08625-0381 WC-365.1 5/7/2015 EMPLOYEE CLAIM PETITION SUPPLEMENTAL PAGE Case No.: ______________________________ Vicinage: ______________________________ GUARDIAN OR REPRESENTATIVE NAME: ADDRESS: RELATIONSHIP TO PETITIONER: ADDITIONAL CARRIERS NAME: ADDRESS: NAME: ADDRESS: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: NAME: ADDRESS: TO: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: NAME: ADDRESS: TO: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: TO: CARRIER CLAIM NUMBER: PERIOD OF COVERAGE: FROM: TO: INDIVIDUAL CORPORATE OFFICERS/PARTNERS/LLC MEMBERS NAME: ADDRESS: NAME: ADDRESS: NAME: ADDRESS: NAME: ADDRESS: American LegalNet, Inc. www.FormsWorkFlow.com