Date: __________________________________
Member: _______________________________
Member ID# ____________________________
Date of Accident/Illness: __________________
From: _________________________________
Dear Member:
We would appreciate your prompt attention to the items checked below:
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Please have the attached form completed in its entirety. We need the original form
returned to us in order to process your claim.
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Since our disability plan is a supplemental one, it is necessary that you provide us with
payment detail information. Please submit photocopies of your weekly state or private
plan disability or worker’s compensation check. You can fax this information to us at
973-671-6821.
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If your disability claim is determined to be eligible through the NJ State Plan, you will
need to provide the payment detail page of the ABSTRACT. There are 2 ways to gather
this:
1.
For Disability While Employed, please call the Temporary Disability Benefits office at
609-292-7060 or access through the internet with the following steps:
Google- NJ Temporary Disability. Click on “Web Services.” Click on “Access Web
Inquiry” and create a new user name and password to view your claim. Once you enter
and view your claim, you will be able to print a payment detail page.
2.
For Disability During Unemployment, please call 609-292-3842 to have an
ABSTRACT mailed to you. This is the only way to receive the abstract necessary to
process your application.
Please note: A new abstract needs to be submitted every time you are paid from the
State in order to process your supplemental disability benefits.