State of New Jersey
|State of New Jersey |ORDER FOR DISMISSAL |CASE NO’S.: |
|Department of Labor and Workforce Development | | |
|DIVISION OF WORKERS’ COMPENSATION | | |
| | | |
|WC-100-Dismissal Interactive (r. 7/1/2013) | | |
| | |VICINAGE: |
|PETIT|NAME: |ATTORN|FEDERAL EMPLOYER NUMBER: |
|IONER| |EY FOR| |
| | |PETITI| |
| | |ONER | |
| |DATE OF BIRTH: | |NAME: |
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| |ADDRESS: | |ADDRESS: |
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| |vs | |TELEPHONE NUMBER (AREA CODE): |
|RESPO| | | |
|NDENT| | | |
| |NAME: | |APPEARING: |
| | | | |
| |ADDRESS: | |NAME |
| | |INSURA|SELF-INSURED TPA |
| | |NCE | |
| | |CARRIE| |
| | |R | |
| | | |ADDRESS: |
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|ATTOR|NAME: | | |
|NEY | | | |
|FOR | | | |
|RESPO| | | |
|NDENT| | | |
| |ADDRESS: | |CLAIM NUMBER: |
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| |TELEPHONE NUMBER (AREA CODE): | | |
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| |APPEARING: | | |
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|THIS MATTER HAVING COME BEFORE THE COURT ON THIS | |DAY OF | |, | |
| ORDER FOR DISMISSAL WITHOUT PREJUDICE |
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|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. |
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|Other: |
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| ORDER FOR DISMISSAL WITH PREJUDICE |
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|Failure to Sustain Burden of Proof |
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|Other: |
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|ALLOWANCES |REIMBURSE |TAX IDENTIFICATION NUMBER |TOTAL AMT. ALLOWED |PAYABLE BY |PAYABLE BY RESPONDENT |
| | | | |PETITIONER | |
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|STENOGRAPHIC SERVICE: | | | | | |
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|WE HEREBY CONSENT TO THE ENTRY AND FORM OF THIS ORDER AND ACKNOWLEDGE RECEIPT | | |
|OF COPY: | | |
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|PETITIONER’S ATTORNEY | |JUDGE OF COMPENSATION |
| | |DATE |
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|PETITIONER (where applicable) | |JUDGE’S NAME |
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| | |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. |
| | | |
|RESPONDENT’S ATTORNEY | | |
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