Order (Judgment Or Approving Settlement) With Case Exhibit Listing {WC-100}

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-100 (r. 8/27/2015) NAME: ORDER JUDGMENT APPROVING SETTLEMENT CASE NO'S.: VICINAGE: FEDERAL EMPLOYER NUMBER DATE OF BIRTH: MEDICARE ELIGIBLE: ADDRESS: ATTORNEY FOR PETITIONER PETITIONER NAME: YES NO ADDRESS: vs RESPONDENT NAME: TELEPHONE NUMBER (AREA CODE): APPEARING: ADDRESS: NAME RESPONDENT IS SELF-INSURED TPA INSURANCE CARRIER ADDRESS: NAME: ATTORNEY FOR RESPONDENT ADDRESS: CLAIM NUMBER: DATE OF ACCIDENT OR OCCUPATIONAL EXPOSURE: TELEPHONE NUMBER (AREA CODE): DESCRIBE (Briefly): APPEARING: ADMINISTRATIVE DISMISSALS (List Other Insurance Carriers to be dismissed from case, without prejudice): Weekly Wages : $ Rate(s): $ / $ IF RE-OPENED PETITION, INDICATE FOR LAST AWARD: Date: Award: Permanent Paid: $ DAY OF Temporary Paid: , $ THIS MATTER HAVING COME BEFORE THE COURT ON THIS It appearing that the Petitioner suffered a compensable injury on the above mentioned date while in the employ of respondent; It is Ordered and Adjudged that Petitioner be awarded compensation benefits, payable as indicated on Page 2. The parties having settled the matter and a finding by the Court having been made that the terms of the settlement are fair and just; It is Ordered that this settlement be approved and the petitioner be paid as indicated on page 2. ORDER FOR JUDGMENT ORDER APPROVING SETTLEMENT PERMANENT DISABILITY (Describe Percentages below followed by the Nature and Extent of Injury and Members involved): % of American LegalNet, Inc. www.FormsWorkFlow.com State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-100 (r 8/27/2015) ORDER JUDGMENT APPROVING SETTLEMENT CASE NO'S.: VICINAGE: DISABILITY AWARDED: TEMPORARY: PERMANENT: Credits: Bonafide Voluntary Tender weeks at $ weeks at $ Non Bonafide Voluntary Tender =$ =$ Reopener Credit less $ less $ N.J.S.A. 34:15-40 paid = Balance due $ paid = Balance due $ __________________________________________ MEDICAL BILLS (Doctors and/or Institutions) AND/OR MISCELLANEOUS INFORMATION: ORDER FOR CHILD SUPPORT MEDICARE ADDENDUM ATTACHED REIMBURSE ADDENDUM ATTACHED TOTAL AMT. ALLOWED PAYABLE BY PETITIONER PAYABLE BY RESPONDENT ALLOWANCES MEDICAL FEE ALLOWED: (report and/or testimony) TAX IDENTIFICATION NUMBER INTERPRETER: ATTORNEY(S) FEE: STENOGRAPHIC SERVICE MISCELLANEOUS FEES: (list below) The Court finds the parties adequately considered Medicare interest, be that as it may, should a Medicare issue arise, this Court retains jurisdiction. WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY: THE COURT FINDS THIS SETTLEMENT FAIR AND JUST. PETITIONER'S ATTORNEY JUDGE OF COMPENSATION DATE PETITIONER (where applicable) JUDGE'S NAME THE ORIGINAL OF THIS DOCUMENT, SIGNED BY THE JUDGE OF COMPENSATION, WILL BE MAINTAINED ON FILE IN THE DIVISION OF WORKERS' COMPENSATION, PURSUANT TO N.J.S.A. 34:15-121 et. seq. American LegalNet, Inc. www.FormsWorkFlow.com RESPONDENT'S ATTORNEY State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-168 r. 8/27/2015 CASE EXHIBIT LISTING FOR: PETITIONER RESPONDENT CASE NO'S.: VICINAGE: Judge: Petitioner: Petitioner Attorney: Hearing Date No. ID Ev. Description Respondent: Respondent Attorney: Retained Court Atty. Reporter Page of American LegalNet, Inc. www.FormsWorkFlow.com