New Jersey Temporary Disability Benefits Application
AbSolve Leave Administration
P.O. Box 1328, Mt. Laurel, NJ 08054
Tel. (800) 401-2691
Fax (800) 728-7028
PART AYOUR INFORMATION
Social Security Number * If you would like a copy of this application, please print it before submitting!
Para llenar esta solicitud en español, haga clic aquí.
Items with a red * are required!
For instructions on this form click here. Para obtener instrucciones sobre este formulario en español, haga clic aquí.

Profile Information

Last Name
*		 First Name
*		 Middle Initial  Gender
          *		 Date of Birth
*		 E-mail address
Home Address-Street address, Apt#
*		 City
*		 State
*		 Zip code
*		 Country
*
Mailing Address (if different)-Street address, Apt#
 Mailing City
 Mailing State
 Mailing Zip code
 Phone (###-###-####)
*

Disability Information

First date you were unable to work and under medical care for this disability (include Saturday, Sunday or holiday).*

Date you recovered or returned to work.
Date(s) of emergency room care or hospitalization.
(if dates are provided, attach proof- e.g. discharge papers)		 from to
Describe your disability (for injuries, explain how and where it happened).* *
Physician's name *City * State *Phone (###-###-####)*
Was this injury or illness caused by your job? * Yes No
If yes, have you or your employer(s) filed, or intend to file, a Workers' Compensation claim? Yes No

Additional Benefit Information

Do you want federal income tax withheld weekly from your benefits? * Yes No
If yes, enter the weekly dollar amount to be withheld (not percentage) $ (amount must be at least $20)
During the period of this disability covered by this claim, have you received or applied for any of the following:
Federal Social Security Disability benefits?* Yes No If yes, enter start/application date
Pension benefits from your current employer?* Yes No If yes, enter start date Monthly amount $
Temporary Disability benefits from another state?* Yes No
Unemployment Insurance benefits?* Yes No

Certification and Signature

I certify that 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.
Sign Here:

EMPLOYMENT INFORMATION

PART B
Instructions: Starting with your last employer, provide information for all your employers in the 6 months before your leave began.
Name of your most recent employer*
 Federal Employer Identification Number (FEIN- you will need to get this from your employer)*
Employer Address*
 Employer City*
 Employer State*
Date of hire* to last physical day of work before your disability* Full time     I work 100% remotely (either FT or PT)
Part time
Union Yes No Occupation Work location  City State
Separation from this employer is
Temporary Permanent		 Which days do you normally work?*
Sun Mon Tue Wed Thu Fri Sat		 Regular weekly earnings*
$
Supervisor's name*   E-mail Supervisor's Phone* (###-###-####)
Have you tried working any days for this employer since you became disabled?* Yes No
(be mindful of this question)		 If yes, give dates to
Have you been paid for any days after your last day of work?* Yes No
If yes, from to 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

Name of other employer (if applicable)
 Federal Employer Identification Number (FEIN- you will need to get this from your employer)
Employer Address
 Employer City
 Employer State
Date of hire to last physical day of work before your disability Full time     I work 100% remotely (either FT or PT)
Part time
Union Yes No Occupation Work location  City State
Separation from this employer is
Temporary Permanent		 Which days do you normally work?
Sun Mon Tue Wed Thu Fri Sat		 Regular weekly earnings
$
Supervisor's name   E-mail Supervisor's Phone (###-###-####)
Have you tried working any days for this employer since you became disabled? Yes No
(be mindful of this question)		 If yes, give dates to
Have you been paid for any days after your last day of work? Yes No
If yes, from to 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

If you have additional employers, please download this document, fill it out and attach below.

This PDF will need to be filled out by your doctor.

And this PDF will need to be filled out by your employer.

Add Attachments below.


Click the Add More Attachments to add more attachments.