IMPORTANT INFORMATION AND REMINDERS

You have successfully submitted your Application for Temporary Disability Insurance benefits. Please make a
note of your claim identification number listed below:

Your Claim Identification Number: 156913

It is your responsibility to print or save the requested forms and submit the instructions to your physician(s) and
employer(s) to file online.

If the medical certification is not submitted online by your physcian within fourteen (14) days, your claim will
be determined ineligible. Your claim will be reviewed upon receipt of the required information.

If you printed a Request to Claimant for Information Form C-01, additional information must be provided
within fourteen (14) days. If this requested information is not received within fourteen (14) days, your claim
will be determined ineligible. Your claim will be reviewed upon receipt of the required information.

You must notify our office immediately if there is a change for any of the circumstances listed below and it was
not previously reported to the Division of Temporary Disability Insurance:
• You return to work or recover from your disability
• Your mailing address has changed
• You receive paid time off or wages from your employer
• You receive a pension from your last employer
• You receive workers' compensation benefits, Social Security Disability
benefits or disability benefits from your employer or union
If you are eligible for benefits, your benefit payments will be deposited to a debit card. Additional information
pertaining to debit cards can be found on our website at:

http://lwd.dol.state.nj.us/labor/tdi/content/debit_cards.html

If you require any assistance with your claim, call:

Customer Service Section (609) 292-7060.

Telecommunication Device for the Deaf (TDD) (609) 292-8319
New Jersey Relay Service: TT user 1-800-852-7899 Voice User: 1-800-852-7897

Division of Temporary Disability Insurance FAX number: (609) 984-4138

For additional information about the Temporary Disability Benefits Program, visit our website
at: http://lwd.dol.state.nj.us/labor/tdi/tdiindex.html

If your disability is expected to last for one year or longer, you may be eligible for Federal Social Security
Disability benefits. The toll free number for Social Security is 1-800-772-1213.

For your convenience a brief summary of the information you have provided on your application has been
displayed on the following pages.
2/25/2019
 Temporary Disability Insurance Claim Summary
Claim Identification Number: 156913

Claimant Profile
Name: Murray, Heather A

Social Security Number: XXX-XX-4930 Date of Birth: 02/12/1973 US Citizen or National: Yes

Address: 52 WASHINGTON PL
EAST RUTHERFORD
NJ 07073

Occupation: TEACHER ASSISTANT

Email: Winegirl1717@Yahoo.com

Primary Phone #: (201)456-4592 Secondary Phone #: (201)456-4592

Disability Information

Last Day Worked: 02/05/2019 First Day Disabled: 02/06/2019

Estimated or Actual Recovery/Return to Work Date: 03/15/2019

Was your disability work related? No

Doctor’s Name: James Cahill

Doctor’s Phone #: (201)489-0022

Other Benefit Sources

Temporary Disability Benefits from another State: No

Social Security Disability Benefits: No

Disability Benefits from your Employer or Union: No

Unemployment Insurance Benefits: No

Withholdings and Late Filing

Federal Income Tax withholding requested? Yes Amount: $20.00

Claim filed beyond 30 days from the First Day Disabled? No Explanation Provided?

Summary - Page 1 of 3
2/25/2019
 *** The following is a brief summary of the employers that you have provided. Details for your three (3)
most recent employers are listed. If you have any additional employers only the name of those employers
will be listed. ***

Employment Information
Employer #1: the Meadow School

Employer’s Phone #: (201)935-2112

Work Location: Rutherford, NJ
Last Day Worked: 02/05/2019
Receiving PTO, Sick, or Vacation Pay: No
Type:
Receiving Pension: No
Working Intermittently During Disability: No Involved in a Labor Dispute: No

Employer #2: The Meadow School

Employer’s Phone #: (201)935-2112

Work Location: Rutherford, NJ
Last Day Worked: 02/05/2019
Receiving PTO, Sick, or Vacation Pay: No
Type:
Receiving Pension: No
Working Intermittently During Disability: No Involved in a Labor Dispute: No

Employer #3:

Employer’s Phone #:
Work Location:
Last Day Worked:
Receiving PTO, Sick, or Vacation Pay:
Type:
Receiving Pension:
Working Intermittently During Disability: Involved in a Labor Dispute:

Summary – Page 2 of 3
2/25/2019
 Additional Employment

Employer #4:
Employer #5:
Employer #6:
Employer #7:
Employer #8:
Employer #9:
Employer #10:

Information Requested
Note: The following information is required to complete your claim. You can print the following forms and
instructions using the Print Forms Application found at www.nj.gov/labor/PrintFormsApplicationTDI

Request(s) to Claimant:

Medical Certificate (M-01) Instructions

Medical Certificate 19022550058
Employer Statement(s) (E-01) Instructions
the Meadow School
The Meadow School

Summary - Page 3 of 3
2/25/2019