If you are employed in the state of New Jersey and are disabled from working for more than seven (7) days, you may be eligible for Temporary Disability Benefits through the Disability Insurance Plan of the State of New Jersey. Failure to file for these benefits within 30 days from the beginning of your disability could result in a loss of these and other benefits.

The necessary forms can be obtained from your employer, the unemployment office or the Disability Insurance Service, CN 387, Trenton, NJ 08625. After completing your portion we recommend that you hand deliver this form to your physician and employer and make sure that they complete their portions. If you are disabled at a later date, another form must be filed.

If you receive benefits from the Disability Insurance Plan of the State of New Jersey, your automobile insurance carrier will deduct this amount from any income continuation benefits which you may be entitled to receive. If you do not receive benefits from the Disability Insurance Plan due to your failure to apply or your late filing, your automobile insurance carrier may still deduct the amount you would have received from the income continuation benefits for which they are responsible. Therefore, be certain this form is returned to the Disability Insurance Service within 30 days from the beginning of your disability.