Order For Dismissal {WC-100}

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-100-Dismissal Interactive (r. 7/1/2013) ORDER FOR DISMISSAL CASE NO'S.: VICINAGE: ATTORNEY FOR PETITIONER FEDERAL EMPLOYER NUMBER: NAME: ADDRESS: NAME: PETITIONER DATE OF BIRTH: ADDRESS: vs RESPONDENT NAME: ADDRESS: TELEPHONE NUMBER (AREA CODE): APPEARING: NAME SELF-INSURED TPA INSURANCE CARRIER ADDRESS: NAME: ATTORNEY FOR RESPONDENT ADDRESS: CLAIM NUMBER: TELEPHONE NUMBER (AREA CODE): APPEARING: THIS MATTER HAVING COME BEFORE THE COURT ON THIS DAY OF , ORDER FOR DISMISSAL WITHOUT PREJUDICE Lack of Prosecution pursuant to NJSA 34:15-54, subject to the right to apply to the Division of Workers' Compensation to have the petition reinstated for good cause, within one year from the date of this dismissal. Other: Failure to Sustain Burden of Proof Other: ORDER FOR DISMISSAL WITH PREJUDICE ALLOWANCES REIMBURSE TAX IDENTIFICATION NUMBER TOTAL AMT. ALLOWED PAYABLE BY PETITIONER PAYABLE BY RESPONDENT STENOGRAPHIC SERVICE: WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT OF COPY: PETITIONER'S ATTORNEY JUDGE OF COMPENSATION DATE PETITIONER (where applicable) JUDGE'S NAME RESPONDENT'S ATTORNEY 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