New Jersey – Temporary Disability Insurance Application

DS-1 You are responsible for having your healthcare provider and employer complete Parts B & C of this
application. Print clearly and answer ALL questions or your benefits may be delayed.
Part A FILE ONLINE FOR FASTER CLAIM PROCESSING! DS-1(1/19)
1 Name: Last First Middle DSDSDS 2 Date of Birth

_____|_____|_____
Internal Code: DSDSDS 3 Social Security Number

4 Home Address (Street, Apt #, City, State, ZIP Code) 5 County

6 Mailing Address – if different from home address (Street, Apt #, City, State, ZIP Code) 7 Male 8 Occupation
Female
9 Are you a citizen of the United States? Yes No 10 Alien Reg. No. 11 Work Authorization

If NO, answer #10 & 11 and give country of origin: ______________ from ___________ to ___________
12 What was the last day that you actually worked before your disability began? Month Day Year

13 Reason for separation: Illness/Accident/Maternity Terminated Quit

14 What was the first day you were unable to work and under medical care due to this
disability? (Include Saturday, Sunday or holiday.)
15 If you have recovered or returned to work from this disability, give the date
(Do not use dates in the future)

16 Date(s) of emergency room care or hospitalization: from ______|______|______ to ______|______|______

If dates are provided, please attach proof (i.e. discharge papers) Month / Day / Year Month / Day / Year

17 Describe your disability (If an injury, state how and where it happened)___________________________________________________
18 Was this injury or illness caused by your job? (This question must be answered.) Yes or No

If Yes, date of work related injury or illness: ______|______|______

Was your employer notified that your injury was caused by your job? Yes No

19 Physician’s Name ______________________________Address ____________________________Phone ( )__________________

20 Other Benefits – During the period of disability covered by this claim, have you:
a Received any sick or vacation pay? Yes No
b Worked any days, including self-employment? Yes No
If yes, specify employer_____________________________ and dates, from ______|______|______ to______|______|______
21 Since your last day of work, have you received or applied for:
a Federal Social Security Disability benefits? Yes No b Pension benefits from most recent employer? Yes No
If yes, enter start/application date ______|______|______ c Temporary Disability benefits from another state? Yes No
If you received a Social Security award letter, please attach a copy. d Unemployment Insurance benefits? Yes No
22 Certification and Signature: I was unable to work during the period for which I am claiming benefits. I certify that I have read and
understand my benefit rights and responsibilities. I am aware that if I provide any information in this application that I know to be false, or
if I knowingly fail to disclose a material fact, I may be subject to penalties, which may include criminal prosecution. I authorize the State of
NJ to verify my Social Security Account Number, and obtain any medical, employment and Social Security benefit information necessary
to determine my eligibility for benefits.

Sign Here _________________________________________________________________Date_________|__________|__________

Witness signature if claimant writes an “X” ___________________________________________________________________________

Phone ( ) ________________ Alternate Phone ( )_________________ E-Mail ______________________________________

You may designate a representative to obtain claim information for you if you cannot call us yourself. The law permits us to give claim
information only to you or your representative.

23 Representative Name ______________________________________________ Date of Birth__________|__________|__________

Note: The NJ Temporary Disability Benefits program is not a “covered entity” under the Federal Health Information Portability and Accountability Act
(HIPAA). All medical records of the Division, except to the extent necessary for the proper administration of the Temporary Disability Benefits Law, are
confidential and are not open to public inspection. The Division protects all records that may reveal the identity of the claimant, or the nature or cause of
the disability and the records may only be used in proceedings arising under the law. 1
 DS-1 (1/19)
Claimant’s Name _________________________________________________________
Social Security Number
Claimant’s Address ________________________________________________________ __ __ __- __ __- __ __ __ __
Claimant’s Phone ( ) __________________________________________________
IMPORTANT TAX INFORMATION
If you choose to have Federal Income Tax withheld from your disability benefits, list the specific dollar amount
you would like withheld weekly from your benefits. Do not give a % amount.

Weekly amount to be withheld for Federal Income Tax: $___________ (must be greater than $20)

PART A-1 CLAIMANT’S EMPLOYMENT INFORMATION

Instructions: Beginning with your last employer, list all of your employers for full-time, part-time, per
diem work, etc. that you worked for over the past year. For each employer in the last six (6) months, have
Part C completed or complete Part C-1 yourself. Any missing employment will delay your claim.
1a Name and address of your most recent employer: Period of employment: from ____|_____|_____ to____|_____|____
__________________________________________________ month / day / year month / day / year
Work
__________________________________________________ Phone _____________________ Location ___________________
(Street) (City) (State) (ZIP) City State

Occupation ___________________________________________ Full time Part time Union ______________________

Check the days of the week you normally work Sun Mon Tue Wed Thur Fri Sat
1b Employer Name and address: Period of employment: from ____|_____|_____ to____|_____|____
__________________________________________________ month / day / year month / day / year
Work
__________________________________________________
(Street) (City) (State) (ZIP) Phone ____________________ Location ___________________
City State
Occupation ___________________________________________ Full time Part time Union _____________________
Check the days of the week you normally work Sun Mon Tue Wed Thur Fri Sat
1c Employer Name and address: Period of employment: from ____|_____|_____ to____|_____|____
__________________________________________________ month / day / year month / day / year
Work
__________________________________________________
(Street) (City) (State) (ZIP) Phone ____________________ Location _____________________
City State
Occupation ___________________________________________ Full time Part time Union _____________________
Check the days of the week you normally work Sun Mon Tue Wed Thur Fri Sat
1d Employer Name and address: Period of employment: from ____|_____|_____ to____|_____|____
__________________________________________________ month / day / year month / day / year
Work
__________________________________________________ Phone ____________________ Location _____________________
(Street) (City) (State) (ZIP) City State
Occupation ___________________________________________ Full time Part time Union ______________________
Check the days of the week you normally work Sun Mon Tue Wed Thur Fri Sat

If you are submitting this claim more than 30 days after your first day of disability, please give your reason:
_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

If more space is needed, attach an additional sheet of paper. Be sure your name and Social Security number appears on all pages.
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 DS-1 (1/19)
Claimant’s Name _________________________________________________________
Social Security Number
Claimant’s Address ________________________________________________________ __ __ __- __ __- __ __ __ __
Claimant’s Date of Birth __________________________________________________

PART B MEDICAL CERTIFICATE – Have your healthcare provider complete Part B.

N.J.S.A 12:18-1.6 prohibits charging a fee to complete this form.
1 Patient has been under my care for this disability FROM ______|______|______ TO ______|_______|______ _________
first date of treatment most recent treatment frequency

2 Date the patient was unable to perform regular work due to this disability ____________|___________|_________
(Doctor’s signature date must be on or after this date unless this is a pregnancy claim) Month Day Year

3 Estimated recovery date (approximate date patient will be able to return to work) ____________|___________|_________
Month Day Year

4 If now recovered, on what date was the patient first able to work? ____________|___________|_________
Month Day Year

5 Diagnosis (what is the disabling condition)_________________________________________________________________________

___________________________________________________________________ ICD Code___________________________________

6 Do you believe this patient is mentally capable of handling their own affairs, including the use of benefits? Yes No

7a If pregnancy, provide estimated date of delivery: ____________|___________|_________

Month Day Year
b Complications, if any pre-term_______________________________postpartum________________________________

c If pregnancy terminated, enter the date: ____________|___________|_________

Month Day Year
And identify the reason: Birth C-Section Miscarriage Abortion

8 Date(s) of emergency room care or hospitalization: from ______|______|______ to ______|_______|______

Month Day Year Month Day Year

9 Type of surgery _______________________ Date of Surgery ______|______|______ Anticipated Surgery Date ______|______|______
Month Day Year Month Day Year
Is surgery for cosmetic purposes only? Yes No

10 Was this disability Due to an accident at work Due to the nature of the work Not related to their work

11a Was this patient referred to you? Yes No If Yes, name of referring doctor _______________________________________
Referring doctor’s phone ( ) ________________ 11b Name of any specialist treating the patient ______________________________

12 I certify that the above statements describe the patient’s disability and the estimated duration thereof

____________________________________________________ __________________________ ____________________________

Print Doctor’s Name License No. and State* Specialty

______________________________________________________________________________ Phone ( ) _________________________________________

Street Address

______________________________________________________________________________ Fax ( ) ____________________________________

City State ZIP Code

_________________________________________________________ _________|___________|__________ Check, if Resident.

Signature of Doctor Date Signed
The date signed must be on or after the date in Question 2, unless this is a pregnancy claim.

*If completed by a Physician’s Assistant (PA-C), provide the license number of the supervising doctor. 3
 DS-1 (1/19)
Claimant’s Name _______________________________ Phone ( ) ___________________ Social Security Number
__ __ __- __ __- __ __ __ __
Claimant’s Address __________________________________________________________

PART C EMPLOYER STATEMENT – Have your employer or company representative complete Part C.
1 EMPLOYER STATUS 8 BASE WEEKS / BASE YEAR WAGES
Your Federal Employer Identification Number (FEIN) _____________________ A base week is a calendar week in which the N.J.
2 WORK LOCATION employee had gross earnings of $172 or more.
Provide the location that the employee physically reports to work a Total number of Base Weeks __________
City________________________________ State_____________
3 CHECK DAYS OF THE WEEK that the employee normally works b Total Gross Wages in Base Year $ __________
Sun Mon Tues Wed Thurs Fri Sat Varies (52 weeks prior to first day of disability)
4 LAST ACTUAL DAY WORKED before this disability
(Do not use a payroll week ending date) ______|______|______ 9 Weekly Wage (base hrs x rate) $__________
Month Day Year Hourly Rate $_______/hr
a Reason for separation from work ______________________________________ 10 Weekly Wages
b Is separation Temporary? Permanent? Provide claimant’s GROSS earnings in New Jersey
employment and period ending dates.
c Has claimant returned to work? Yes No Note: If the weeks listed below include overtime,
If Yes, give date ______|______|______ bonuses, etc., attach an explanation and separate the
d If the work was intermittent, list dates ________________________________ regular wages earned. Payroll records will not be
5 CONTINUED PAY accepted in place of completing this statement.
a Have you paid or do you expect to pay the claimant for any period after the last Description of Week Gross Wages
day of work? Yes No Calendar Week Ending Date
b If yes, give dates from: _____|_____|_____ to: _____|_____|_____ Week Disability
Month Day Year Month Day Year Began
/ / $
c Amount per week $____________ (if amount varies please attach a list of dates/amounts)
Week before
d Total amount paid for entire given period $______________ Disability
/ / $
e Check the number that best describes the monies paid in item c. 2nd Week Before
1. Paid time off (vacation, sick, personal, etc.) Disability
/ / $
2. Difference between regular wkly wages and disability benefits to be received
3rd Week Before
3. Supplemental benefits (unallocated payout will have no impact)
Disability
/ / $
4. Severance pay With notice In lieu of notice
4th Week Before
5. Pension (attach pension approval letter)
Disability
/ / $
Note: Items 1, 4, and 5 may reduce benefits to the claimant.
5th Week Before
6 GOVERNMENT EMPLOYERS
Disability
/ / $
a Payroll Number (For N.J. state employees) _____________________
6th Week Before
b If claimant has applied for or received donated leave, attach dates and amounts.
Disability
/ / $
7 WORKERS’ COMPENSATION LIABILITY
7th Week Before
a Did the claimant’s disability happen in connection with their work or while on
Disability
/ / $
your premises, or was the disability due in any way to their occupation?
8th Week Before
Yes No
Disability
/ / $
b If Yes, have you filed or do you intend to file a Workers’ Compensation claim
9th Week Before
on behalf of this claimant? Yes No
Disability
/ / $
c If Yes, list Workers’ Compensation Insurance carrier below:
10th Week Before
Name_________________________ Phone ( ) ______________________
Disability
/ / $
Address__________________________________________________________
TOTAL GROSS WAGES FOR
Policy #________________________ Claim #__________________________
ABOVE WEEKS $
I CERTIFY THE INFORMATION GIVEN ABOVE IS CORRECT
Are you exempt from FICA tax? Yes No

Firm Name _______________________________ Phone ( ) ______________

Signature______________________________
Address ___________________________________ Fax ( ) ______________ Do not sign/date before the last day worked
City __________________________ State _________ ZIP Code ______________ Date (required) ________|_________|_________
Name/Title_________________________________________________________ 4
 DS-1 (1/19)
Social Security Number
Claimant’s Name _________________________________________________________
__ __ __- __ __- __ __ __ __
Claimant’s Address ________________________________________________________
CLAIMANT CERTIFICATION OF WAGES & EMPLOYMENT – If any of your employers
in the last six (6) months refuse to complete Part C, or if you are unable to reach them, you are
Part C-1 required to use this form to provide proof of wages & employment in place of Part C. You must
also attach proof of wages (paystubs, W-2 forms, tip records, etc.).
2 EMPLOYER STATUS
1 EMPLOYER NAME_______________________________________ Federal Employer Identification Number (FEIN)______________________

3 EMPLOYER ADDRESS____________________________________________________ ___________________________ __________ __________

Street City State Zip

4 EMPLOYER PHONE (______) ___________________ (HR Office, if available)

5 LAST DAY WORKED 6 WORK LOCATION

My last physical day worked was _____|_____|_____ Provide the location that you physically reported to:
Month Day Year City ______________________________ State ____________
7 BASE YEAR
During the 52 calendar weeks prior to my first day of being disabled I worked _______weeks (with earnings of $172 per week or more) with this

employer. My gross earnings, before deductions, during that time were: $__________________
8 WEEKLY WAGES In the eight (8) weeks prior to my disability or family leave I earned the following with this employer:

Calendar Week-ending Gross Wages Calendar Week-ending Gross Wages

1. ____/____/____ $________________ 5. ____/____/____ $________________

2. ____/____/____ $________________ 6. ____/____/____ $________________

3. ____/____/____ $________________ 7. ____/____/____ $________________

4. ____/____/____ $________________ 8. ____/____/____ $________________

9 CONTINUED PAY
Have you been paid or do you expect to be paid for any period after the last day of work? Yes No
If yes:
Dates paid: from: _____|_____|_____ to: _____|_____|_____ Amount per week $___________ Total amount paid $______________
Month Day Year Month Day Year

Check the number that best describes the monies paid in item c.
1. Paid time off (vacation, sick, personal, etc.)
2. Difference between regular weekly wages and disability benefits to be received
3. Other pay from your employer (explain): _____________________________________________________
4. Severance pay With notice In lieu of notice
5. Pension (attach pension approval letter)
Note: Items 1, 4, and 5 may reduce your benefits.
10 CERTIFICATION AND SIGNATURE
My signature on this form indicates that the statements made by me are true and correct to the best of my knowledge. I make this statement
with knowledge that the wages and employment information set forth herein will be used as a basis for determining the temporary
disability/family leave benefits to which I may be entitled and that any willful misrepresentation or false statement made for the purpose of
obtaining or increasing benefits will render me liable to penalties provided by Temporary Disability Benefits Law (N.J.S.A. 43:21-55).

Date_______________ Claimant’s Signature____________________________________________ Phone (_____) _______________

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 New Jersey Department of Labor and Workforce Development • Division of Temporary Disability Insurance

FILE ONLINE FOR FASTER CLAIM PROCESSING AT:

myleavebenefits.nj.gov
How to complete the Claim for Disability Benefits (form DS-1)
— KEEP THIS PAGE FOR YOUR RECORDS — DO NOT RETURN —
w You (the claimant) must complete the first 2 pages of the application (parts A and A1).
w You are responsible for having your doctor complete part B and for having your employer(s) complete part C.
w If you worked for more than one employer during the past year, you must copy part C for your other employer(s) to
complete. This will help us process your claim more quickly.
w If your doctor and employer(s) submit their parts separately, please complete and return parts A and A1 as soon as
possible. If you cannot submit all parts together, we can process your claim quicker if we receive parts A and A1 first.

For quicker processing

w It is very important that you provide information that is accurate and true. Missing, incorrect, or illegible information
will delay payment of your benefits. Print clearly.
w Write your name and Social Security number on each part of your claim and on all attachments.
w Give exact dates when dates are requested.
w If you need help completing the form, call 609-292-7060. You may need to hold to speak to an agent.

Submitting your application

1. Whenever possible, send all parts of your claim together. Sending separate pages will delay your claim.
Sending duplicate copies will also delay your claim. Send additional copies ONLY if information has changed.
2. If you fax your claim, be sure to fax all 4 pages together (but not these instructions).
3. Send all parts (parts A, A1, B, and C) and any attachments to:
mail: Division of Temporary Disability Insurance / P.O. Box 387 / Trenton, NJ 08625-0387
fax: 609-984-4138

Claimant’s Rights and Responsibilities

To file a claim for temporary disability benefits
It is your responsibility to file this claim immediately after you stop working due to your disability. If you file a claim
before your last day of work, your benefits will be delayed.
By law, you must file a claim within 30 days after the start of your disability. If you file later, benefits may be denied or
reduced. If you file more than 30 days after you disability started, give the reason why on the bottom of part A1.
Other income Return to work
You must tell us about any other income you are
When you recover or return to work, report this date
receiving. This includes sick pay, wages, pension, immediately to the Division of Temporary Disability
workers compensation benefits, Social Security Insurance to avoid overpayment.
Disability benefits, or disability benefits from your
Income tax withholding
employer or union.
If you want federal income tax (F.I.T.) deductions
Continued medical certification
withheld from your disability benefits, attach form W-4S
If you are eligible for TDI benefits, we will periodically (Request for Federal Income Tax Withholding From Sick
send you a request for continued medical certification Pay) to your claim. You can get this form from your
(form P30) to verify that you are still disabled and under employer or the Internal Revenue Service
a doctor’s care. Return the form promptly to guarantee (irs.gov/pub/irs-access/fw4s_accessible.pdf).
continuous benefits.

Online information Help with your claim

about temporary disability benefits:myleavebenefits.nj.gov
Customer Service ...................................... 609-292-7060