DS-1 (6/19)
1 Last name
First name
Middle
DSDSDS
Internal Code
2 Home Address (Street, Apt #, City, State, ZIP Code)
6 County
3 Mailing Address – if different from home address (Street, Apt #, City, State, ZIP Code)
11 Date you recovered or returned to work
Yes
No
Yes
No
Yes
No
Yes
No
If Yes, enter start/application date _______|_______|_______
If Yes, enter start date _______|_______|_______ Monthly amount $_____________
Disability Information
_______|_______|_______
Social Security Number
Profile Information
Additional Benefit Information
Certification and Signature
17
During the period of disability covered by this claim, have you received or applied for:
13 Describe your disability (for injuries, explain how and where it happened)
Physician's Name ___________________________________
7 Phone (_____) _______________
______|______|______
4 Date of Birth
5
Gender
mm | dd | yy
______________
Sign Here ___________________________________________________________________________________________ Date ____|_____|_____
10
and under medical care for this disability
(Include Saturday, Sunday or holiday)
_______|_______|_______
12 Date(s) of emergency room care or hospitalization
from
_______|_______|_______
to
_______|_______|_______
mm | dd | yy
mm | dd | yy mm | dd | yy
mm | dd | yy
__________________________________________________________________________________________
City _______________________________ State ___________
Phone (
_____
) ___________________
14
If yes, enter the weekly dollar amount to be withheld (not percentage) $ _______________ (amount must be at least $20)
If yes, have you or your employer (s) filed or intend to file a Workers' Compensation claim?
Yes No
Witness signature if claimant writes an "X" ____________________________________________________________________________________________________
(If dates are provided, attach proof; e.g. discharge papers)
You may assign a representative to obtain claim information for you if you cannot call us yourself. We can only give claim information to you and your representative.
19 Approved 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.
8
With which racial/ethnic group(s) do you most identify?
9
Check the highest level of schooling you have completed.
Caucasian
African American
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaskan Native
Have not graduated high school
High School Graduate/GED
Associates/Bachelor's Degree
Graduate Degree
1
a Federal Social Security Disability benefits?
b Pension benefits from your current employer?
c Temporary Disability benefits from another state?
d
Unemployment Insurance benefits?
Questions 8 and 9 are for statistical purposes only and do not affect eligibility
15 Was this injury or illness caused by your job?
Yes No
16 Do you want federal income tax withheld weekly from your benefits?
Yes No
18
I certify I was unable to work during the period for which I am claiming benefits. 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. You are hereby authorized to verify my Social Security Number, and obtain any
medical, employment and Social Security benefit information necessary to determine my eligibility for benefits.
Representative Phone Number (_____)________________________________________
YOUR INFORMATION
PART A
Latino/Hispanic Yes No
First date you were unable to work
DS-1
New Jersey Temporary Disability Benefits Application
Division of Temporary Disability & Family Leave Insurance
P.O.
Box 387, Trenton, NJ 08625-0387
Fax: 609-984-4138
Name ______________________________________________________________
Address _____________________________________________________________
Phone (_____)________________________________________________________
Social Security Number
2
Fri
Sat
Date of hire
_____|______|______
_____|______|_____
Sun
Mon
Tue
Wed
Thur
Temporary
8 Separation from this employer is
Which days do you normally work?
mm | dd | yy mm | dd | yy
11 Supervisor's Name _____________________________________
9
Permanent
12
10 Regular Weekly Earnings
$________________________
Company______________________________________________
Street______________________________________________________________City____________________State______________
13 Have you tried working any days for this employer since you became disabled?
If yes, give dates _____|_____|____ to _____|_____|____
Have you been paid for any days after your last day of work?
If yes, from _____|_____|_____ to _____|_____|_____
Yes No
Total amount paid $________________
6 Occupation___________________________
1 Name of your most recent employer
2 Federal Employer Identification Number (FEIN)
DS-1 (6/19)
Yes No
(see box 10 on Part A)
This pay represents:
Severance pay
Donated Leave
In lieu of notice
With notice
Paid time off (vacation, sick, personal, etc.)
Difference between regular wages and disability benefits
Other pay from your employer (explain) ___________________________
4
Full time
Part time
7 Work Location City ______________________ State ______
Instructions: Starting with your last employer, provide information for all your employers in the 6 months before your leave began.
If you need to list more employers, make a copy of this page. Be sure to state the first and last day you physically reported to work. Do not write "present" or "current."
Phone (_____) __________________________________
14
__
PART B
EMPLOYMENT INFORMATION
see instructions
5
Union
YesYes
No
Last physical day of work before your disability
3
to
Fri
Sat
Date of hire
_____|______|______
Which days do you normally work?
Sun
Mon
Tue
Wed
Thur
8 Separation from this employer is
mm | dd | yy
_____|______|_____
mm | dd | yy
11 Supervisor's Name _____________________________________
9
Temporary
Permanent
12
10 Regular Weekly Earnings
$________________________
Company______________________________________________
Street______________________________________________________________City____________________State______________
1
3 Have you tried working any days for this employer since you became disabled?
If yes, give dates _____|_____|____ to
_____|_____|____
Have you been paid for any days after your last day of work?
If yes, from _____|_____|_____ to _____|_____|_____
Total amount paid
$________________
6 Occupation___________________________
1 Name of other employer
2 Federal Employer Identification Number (FEIN)
NoYes
(see box 10 on Part A)
Yes No
This pay represents:
Paid time off (vacation, sick, personal, etc.)
Difference between regular wages and disability benefits
Other pay from your employer (explain) ___________________________
Severance pay
With notice
In lieu of notice
Donated Leave
4
Full time
Part time
7 Work Location City ______________________ State ______
Phone (_____) __________________________________
1
4
__
see instructions
5
Union
YesYes
No
3
to
(if applicable)
Last physical day of work before your disability
Have your healthcare provider complete this page. N.J.S.A 12:18-1.6 prohibits charging a fee to complete this form.
3 Has your patient recovered from this disability? If so, provide recovery date
3
No
Yes
2
Name ______________________________________________________________
Address _____________________________________________________________
Phone (_____) ________________________________________________________
Patient's Date of Birth _________________________________________________
Social Security Number
1 Patient has been under my care for this disability
FROM ______|______|______
TO ______|_______|______
_________
first date of treatment most recent treatment frequency
Date the patient was unable to perform regular work due to this disability
______|_______|______
mm | dd | yy
______|_______|______
mm | dd | yy
4 Estimated recovery date
______|_______|______
mm | dd | yy
(If patient has not recovered, provide approximate date patient will be able to return to work)
5 Diagnosis (describe the disabling condition) ________________________________________________________________________
__________________________________________________________________# ICD Code_____________________________________
6 Do you believe this patient is mentally capable of handling their own affairs, including the use of benefits?
7 If disability is due to pregnancy, provide the estimated date of delivery
a Pre-term complications _______________________________ Postpartum complications ________________________________
b If patient has delivered, enter the delivery date
______|_______|______
mm | dd | yy
______|_______|______
mm | dd | yy
Identify the type of delivery Birth C-Section Miscarriage Abortion
8 Date(s) of emergency room care or hospitalization from ______|______|______ to ______|_______|______
mm | dd | yy
mm | dd | yy
9 Type of surgery ________________________________________________ Date of Surgery ______|______|______
Is surgery for cosmetic purposes only?
No
Yes
10 Was this patient referred to you?
No
If yes, name of referring doctor _______________________________________
Yes
HEALTHCARE PROVIDER CERTIFICATION AND SIGNATURE
Anticipated Surgery Date ______|______|______
DS-1 (6/19)
Print Name __________________________________________ Signature ___________________________________ Date __________
Certificate License No. and State ________________________ Physician Specialty ___________________________________________
Street Address _____________________________________________________________________________
Check, if Resident
City ____________________________________________ State _____________ ZIP Code ________________
Phone (_____)__________________________________ Fax (_____) ________________________________
PART C
MEDICAL CERTIFICATE
I certify the
above statements describe the patient's disability period:
New Jersey Department of Labor and Workforce Development • Division of Temporary Disability Insurance
FILE ONLINE FOR FASTER CLAIM PROCESSING AT
How to Complete the Claim for Temporary Disability Benets
• This application (form DS-1) is for disability leave. If you wish to claim benefits for family caregiving or bonding,
complete the application for Family Leave Benefits (form FL-1).
• You must complete the first 2 pages of the form (Parts A and B).
• You will need to provide your employer’s Federal Employer Identification Number on Part B. You can get this number
from either your last year’s W-2 form or your Human Resources office. Your employer is not required to complete
this form but you can ask them to help you with any questions on Part B.
• Part C must be completed by your healthcare provider.
• You have 30 days from the first day of your disability to file your claim. If your claim form is received more than 30
days from the first day of your leave, you must provide a reason why the claim was not filed on time. Benefits may be
reduced or denied for late applications.
Remember
• You must complete every question accurately and write legibly.
• Any missing information may cause your claim to be denied.
• Demographic questions have no effect on the approval or denial of your claim.
• Write your name and Social Security number on each page of your claim and on all attachments.
• Exact dates must be given. Do not write “present” or “current.”
• If you need to list more than 2 employers, make a copy of Part B to list additional employment.
• If you return to work while you are claiming Temporary Disability benets, report this date immediately to the
Division of Temporary Disability Insurance to avoid overpayment.
How to Send Us Your Claim Form
There are 2 options for you to submit this form. Choose only one, as sending multiple copies will delay processing.
If you led your claim online, do not also submit a paper application.
1. Fax this completed form to 609-984-4138
– OR –
2. Mail this completed form to: Division of Temporary Disability Insurance / P.O. Box 387 / Trenton, NJ 08625-0387
After Submitting Your Claim
• After being approved for Temporary Disability benets, you may receive a form (P-30) “Request to Claimant for Con-
tinued Claim Information.” Use this form to claim additional benets. You and your healthcare provider can complete
your parts online to ensure uninterrupted benets.
• You can nd information and check your claim status at myLeaveBenets.nj.gov
• For more help on your claim, call Customer Service at 609-292-7060
