Request For Records Inspection {WC-147}

Department of Labor and Workforce Development Division of Workers' Compensation P O Box 381 Trenton, New Jersey 08625-0381 State of New Jersey REQUEST FOR RECORDS INSPECTION WC-147 (R 6-27-2014) Requestor Information: 1. Requestor Name: 3. Company Name: 5. Address: 2. Telephone: 4. Requestor File No: 6. Account No. (Required, if requestor has an existing account): If you're a previous requestor, please check if above is a new address 7. E-Mail Address *: * E-Mail to be used for routine account communications with you I am seeking records pertaining to the following injured worker and specified cases: 1. Injured Social Security Number (required): 3. Identify Cases (one selection must be made): 2. Injured Name (required): The following Claim Petition(s): All cases for this injured worker __________________________________________________________________ 4. Records Requested from each Claim Petition file: All cases except for the following: __________________________________________________________________ Claim Petition/Answer Medicals/Exhibits Closure Documents Entire Case File * for Re-Opened case files, only documents dated after the last closure will be provided unless otherwise requested The following statement must be completed, signed, dated and submitted to the Div. of Workers' Compensation at the address shown above. Copies of documents provided through this request shall adhere to the provisions of N.J.S.A. 34:15-128, et seq which limits the inspection and copying of workers' compensation records. CERTIFICATION (Check the appropriate box and complete the required information.) I, the undersigned, do hereby certify that I am the petitioner, the employer or the insurance carrier as indicated below and that I am requesting the above record(s) to conduct an investigation in connection with a pending workers' compensation case, to which I am a party and certify that the record(s) will be used only for purposes directly related to the case. _____ Petitioner _____ Employer _____Insurance Carrier I, the undersigned, do hereby certify that I am the authorized agent for the petitioner, the employer or the insurance carrier as set forth in the attached written agent authorization and that I am requesting the above record(s) to conduct an investigation in connection with a pending workers' compensation case, to which I am the authorized agent for a party and certify that the record(s) will be used only for purposes directly related to the case. Agent for: _____ Petitioner _____ Employer _____Insurance Carrier _____ Written Agent Authorization Attached I the undersigned do certify that I am a third party directly involved in a workers' compensation case my status set forth below or the authorized agent of the third party involved in a workers' compensation cases whose status is set forth below in the attached written agent authorization and that I am requesting the above record(s) to conduct an investigation in connection with the case and certify the record(s) will be used only for purposes directly related to the case. Indicate third party status: _____ Lienholder _____ PIP Carrier ______________________________ Other (specifically identify) _____ If Agent, Written Agent Authorization Attached I, the undersigned do certify that petitioner has authorized the release to me of the above record(s) pursuant to the petitioner signed written authorization attached for the release of the record(s). I also certify that the release and/or use of the record(s) do not violate N.J.S.A. 34:15-128 (d). _____ Written Authorization Attached I certify that the foregoing information made by me is true. I am aware that if any of the foregoing information made by me is willfully false, I am subject to punishment. Signature: Printed Name: ____________________________________________________________ ____________________________________________________________ Date: _______________________________ Fees: Copies are certified and billable at a rate of $.05 per page. Billed amounts are due upon presentation. The Division also reserves the right to deny records requests by any requestor where payment for previous copy work remains unpaid for a period of sixty (60) days or more following delivery and billing for same. American LegalNet, Inc. www.FormsWorkFlow.com