The New Jersey Employee Claim Petition, known as Form WC-365, is the legal document an injured worker files to open a formal workers’ compensation case against an employer and its insurance carrier with the New Jersey Division of Workers’ Compensation. You file it when your employer or its insurer denies, delays, underpays, or stops the benefits you believe you are owed after a job-related injury or illness.
This form turns a stalled or disputed claim into a real court case with a judge, a hearing schedule, and the power to order medical treatment, lost-wage checks, and a permanent disability award. Each year the Division handles tens of thousands of new petitions, and filing within the two-year deadline set by N.J.S.A. 34:15-51 is the single thing that keeps your right to those benefits alive. Miss it, and a judge can throw your case out before it ever starts.
Here is what you will learn in this guide:
- 📄 What Form WC-365 does and who has to file it
- 🗂️ Every document and number you need before you start
- ✍️ A line-by-line walkthrough of each box on the petition
- 👥 Three real filing scenarios from start to finish
- ⚖️ The deadlines, mistakes, and after-filing steps that decide your case
What the Form Is and Who Must File It
Form WC-365 is the Employee Claim Petition published by the Department of Labor and Workforce Development, Division of Workers’ Compensation, in Trenton. The version in use carries the revision date 8/26/2015 printed in the top-left corner, so check that you are holding the current form before you write anything. The petition asks the Division to “determine the amount of compensation due Petitioner from said Respondent, pursuant to R.S. 34:15-7 et seq.”
You must file this petition if you were hurt on the job or developed a work-related illness and you cannot resolve your benefits with your employer’s insurance carrier. You do not file it for every injury. Many claims are paid voluntarily, and you never see a courtroom. You file the petition when benefits are denied, when temporary checks stop too soon, when treatment is refused, or when you want a permanent disability award entered after you finish treatment.
The person filing is the Petitioner, which is you, the injured worker. The Respondent is your employer and its insurance carrier or self-insured entity. The case is decided by a Judge of Compensation inside the Division, not in regular civil court. The Division has exclusive jurisdiction over work-injury disputes, which means you cannot sue your employer in Superior Court for these benefits.
A worker who is unsure whether to fight may instead file an Application for an Informal Hearing (Form WC-66), a lighter process where a judge gives a non-binding suggestion. The Claim Petition is the formal, binding route. Most workers facing a flat denial choose the Claim Petition because the informal hearing produces no enforceable order.
Before You Start: Documents and Information You Need
Gathering your facts before you open the petition saves you from guessing and from filing a petition full of blanks. The Division reads every box, and missing data slows your case or invites the carrier to deny details. Pull these items together first.
- Your Social Security number. The form requests it for record-keeping and cross-matches with the Social Security Administration; if you leave it off you must check the “SSN Not Available” box, which can delay matching your file.
- Your employer’s exact legal name and address. Naming the wrong entity, such as a store brand instead of the corporate owner, can let the real employer dodge the case.
- The insurance carrier’s name and address. Without it the Division cannot serve the right party, and your petition may sit unanswered.
- The carrier claim number. This is the number the insurer assigned when the injury was first reported; it links your petition to the existing claim file.
- The date of accident or last exposure. This date starts the two-year clock and must be exact, because the carrier checks it against its own records.
- The date you reported the injury and who you told. New Jersey gives you 90 days to notify your employer, and the name of the supervisor proves you met that rule.
- Your gross wages and pay period. These set your weekly benefit rate, so a wrong wage figure means a wrong check amount.
- Your medical records and a clear description of the injury. You need the body parts hurt and how it happened to complete the injury section and to demand treatment records.
- Your Medicare and Medicaid status. The form asks three eligibility questions because federal law requires the Division to protect Medicare’s interest in any settlement.
Where to Get the Form and How to Access It
You get the official Employee Claim Petition straight from the Division’s Forms and Publications page, where it is listed under Formal Litigation Forms, Petitioner Forms, as document wc-365 with a version date of 8/26/15. Download the PDF and print it if you plan to file on paper. The supplemental page, WC-365.1, is a separate download you use only when you have extra carriers, a guardian, or named corporate officers.
Most petitions today move through the Division’s electronic system, COURTS on-line, the Division’s online case-management and e-filing website. Law firms, insurance carriers, and self-insured employers file there after completing a COURTS on-line Internet Access Application. The portal walks the filer through the same fields that appear on the paper form, then assigns a case number automatically.
A worker filing without a lawyer can still file the paper WC-365 by mail to the Division. The paper form and the online screens ask for identical information, so learning the paper layout prepares you for either path. Whichever route you choose, you complete the same boxes covered below.
Step-by-Step: How to Fill Out Form WC-365 Line by Line
The petition is organized from the top down: case identifiers, then the Petitioner block, then the Employer and carrier block, then injury and employment details, then the verification and signature. Fill the boxes in the order they appear so you do not skip anything.
1. New Filing or Amended Filing Checkbox
At the very top the form gives you two boxes: NEW FILING and AMENDED FILING. This box tells the Division whether you are opening a brand-new case or changing one that already exists.
To answer it, check NEW FILING if this is your first petition for this injury. Check AMENDED FILING only if a case is already open and you are correcting or adding to it.
For example, Maria Lopez hurt her back last month and has never filed before, so she checks NEW FILING and leaves the amended box empty.
A common edge case is the reopener: if you want to revisit an old, closed award, you do not use this checkbox at all, you use the separate Application for Review or Modification (Form WC-368).
A frequent mistake here is checking AMENDED FILING on a first petition, which makes the Division look for a case number that does not exist and bounces your filing. People often believe “amended” means “more serious,” but it only means you are editing a case already on file.
2. Case Number and Vicinage
Right below the checkboxes are blanks for Case No. and Vicinage. The form says in bold to “please enter above only if filing an Amended Claim.”
To answer, leave both blank on a new filing. The Division assigns your case number and your vicinage, which is the district office that will hear your case, after you file.
For example, Maria Lopez leaves Case No. and Vicinage empty because her petition is new.
The edge case is an amended filing, where you copy the existing case number exactly from your prior paperwork. A wrong digit sends your amendment to the wrong file.
A common mistake is a pro se worker inventing a case number to look official, which confuses the clerk and delays docketing. Many people think vicinage means their home county, but it is the Division district office, and the Division picks it based on where you live or where the injury happened.
3. Petitioner Social Security Number
The first Petitioner box asks for your SOCIAL SECURITY NUMBER, with a checkbox for SSN Not Available.
To answer, write your nine-digit number in the standard format. If you truly have no SSN, check the SSN Not Available box instead of leaving it blank.
For example, Maria Lopez enters 123-45-6789 in the box.
The edge case is a worker without lawful status who has no SSN; that worker checks SSN Not Available and may still pursue benefits, since coverage does not turn on immigration status.
A common mistake is transposing two digits, which breaks the cross-match with Social Security records and can stall verification. People wrongly fear the number triggers immigration enforcement, but the form states the SSN is used only for record-keeping and benefit cross-matches under the Privacy Act.
4. Attorney for Petitioner and Tax Identification Number
This block holds the ATTORNEY FOR PETITIONER name and a TAX IDENTIFICATION NUMBER, along with the attorney’s NAME, ADDRESS, TELEPHONE NUMBER, and FAX NUMBER.
To answer, your lawyer enters the firm name, the firm’s tax ID, and contact details. If you file pro se, write “Pro Se” or “Self-Represented” and leave the tax ID blank.
For example, attorney David Chen of Chen Law writes his firm name, the firm tax ID, and the office address and phone.
The edge case is a worker who hires a lawyer later; the attorney then files a Substitution of Attorney (Form WC-10) rather than amending this box.
A common mistake is leaving the contact lines blank, which means the Division and carrier have no way to reach you about hearings, and you can miss a date and risk dismissal. People assume they must have a lawyer to file, but a worker may file pro se, though most hire counsel because attorney fees come out of the award, not your pocket up front.
5. Petitioner Name, Address, Date of Birth, and Sex
This block asks for your NAME, ADDRESS, DATE OF BIRTH, and SEX, plus your own TELEPHONE NUMBER.
To answer, write your full legal name as it appears on your Social Security card, your current mailing address, your birth date, and your sex. Use a date format like MM/DD/YYYY for clarity.
For example, Maria Lopez writes her name, 03/14/1985 as her date of birth, and her home address and cell number.
The edge case is a recent move; always list the address where you actually receive mail, and update the Division in writing if you move during the case, because all hearing notices go to that address.
A common mistake is using a nickname instead of a legal name, which creates a mismatch with medical and wage records and can slow proof of your claim. People think the address is just a formality, but it is the legal service address, and a missed notice mailed there can lead to dismissal for non-appearance.
6. Guardian or Representative Checkbox
A checkbox states that “A guardian or other representative is filing on behalf of the petitioner. See Supplemental Page for details.”
To answer, check this box only if someone is filing for you because you are a minor or cannot act for yourself, then complete the guardian section on the WC-365.1 supplemental page.
For example, Robert King’s adult daughter files on his behalf after a stroke left him unable to manage his affairs, so she checks the box and lists her name and relationship on the supplement.
The edge case is a deceased worker; survivors do not use this box but file a separate Dependency Claim Petition (Form WC-366) instead.
A common mistake is checking the box but never completing the supplemental page, which leaves the guardian’s authority unproven and stalls the case. People think any helper counts as a guardian, but the box is for legal representatives acting for someone who cannot act alone.
7. Employer Name and Different Name Field
The Employer block starts with the employer NAME and a line that reads “IF EMPLOYER IS KNOWN BY DIFFERENT NAME, PLEASE INDICATE HERE.”
To answer, write the exact legal name of your employer, then add any trade name, store name, or “doing business as” name on the different-name line.
For example, Maria Lopez writes Garden State Logistics LLC as the legal name and notes “GSL Warehouse” as the name on her badge.
The edge case is a staffing agency: you may name both the agency that pays you and the host company where you worked, since either may be the responsible employer.
A common mistake is naming only the store brand on your uniform, which lets the corporate employer claim it was never properly named. People assume the name on their paycheck is always correct, but payroll companies and franchises often differ from the true legal employer.
8. Employer Address
Below the name is the employer ADDRESS.
To answer, list the employer’s main business address or the address of the location where you worked.
For example, Maria Lopez lists the warehouse street address in Edison, New Jersey.
The edge case is an out-of-state employer with New Jersey work; list the local job site so the Division can confirm New Jersey jurisdiction over the injury.
A common mistake is using your own home address by accident, which sends notices to the wrong party. People think any company address works, but using a closed or wrong branch can delay service on the employer.
9. Insurance Carrier or Self-Insured Entity Name and Address
This block asks for the INSURANCE CARRIER or SELF-INSURED ENTITY NAME and ADDRESS, plus the CARRIER CLAIM NUMBER.
To answer, copy the insurer’s name and the claim number exactly as they appear on any letter or benefit notice you received. If you do not know the carrier, you can search the insurer database when filing online.
For example, Maria Lopez enters Liberty Mutual and the claim number WC-4471892 from her denial letter.
The edge case is a worker with no paperwork; you may leave the carrier blank if it is truly unknown, and the Division can help identify it, though doing so slows the case.
A common mistake is guessing the claim number, which can attach your petition to the wrong file. People assume the employer’s HR department is the carrier, but the carrier is the insurance company that pays claims, listed on the workers’ compensation notice posted at work.
10. Status of the Employer
The form asks you to INDICATE THE STATUS OF THE EMPLOYER with four boxes: INSURED, UNINSURED, SELF-INSURED (PRIVATE), and SELF-INSURED (GOVT. AGENCY).
To answer, check the one box that matches your employer. Most private employers are insured; large companies and government bodies are often self-insured.
For example, Maria Lopez checks INSURED because her warehouse carries a Liberty Mutual policy.
The edge case is an uninsured employer; check UNINSURED, because that routes your case toward the Uninsured Employers Fund, which can pay limited benefits when no insurer exists.
A common mistake is checking INSURED when the employer carried no policy, which delays the Uninsured Employers Fund process you actually need. People think every employer must be insured, but some break the law and carry no coverage, which changes how your case proceeds.
11. Period of Coverage and Additional Carriers
The form provides a PERIOD OF COVERAGE with FROM and TO dates, plus a checkbox to “See Supplemental Page for additional carriers.”
To answer, enter the coverage dates if you know them, and check the supplemental box if more than one carrier insured the employer during your exposure.
For example, in an occupational case spanning years, Sam Rivera checks the additional-carriers box and lists each insurer on the WC-365.1 page.
The edge case is occupational disease with several insurers over time, where naming every carrier on the supplement protects your right to recover from the correct one.
A common mistake is omitting a carrier that covered part of a long exposure, which can leave a gap in liability. People think only the current carrier matters, but in disease cases the carrier on the risk during exposure can be responsible.
12. Uninsured Corporate Officers Checkbox
A checkbox states that “If uninsured, individual corporate officers, or others, are also named as respondent(s). See Supplemental Page for details.”
To answer, check this box only when the employer is uninsured and you want to name the owners or officers personally, then list them on the supplemental page.
For example, when Sam Rivera’s uninsured contractor employer has no policy, his attorney names the company owner personally and checks this box.
The edge case is a dissolved company; naming the officers personally may be the only way to reach any recovery.
A common mistake is skipping this box against an uninsured employer, which can leave no party able to pay. People think they can never reach an owner’s personal assets, but in uninsured cases the law allows naming responsible officers.
13. Date of Accident or Last Exposure
The injury section opens with Date of Accident or Last Exposure.
To answer, enter the exact date your injury happened. For an illness that built up over time, enter the last date you were exposed to the harmful condition at work.
For example, Maria Lopez writes 02/10/2026, the day she felt her back give out lifting a pallet.
The edge case is repetitive injury with no single date; use your last day of exposure, which is often your last day of work in that job.
A common mistake is guessing the date, which can place your filing outside the two-year window under N.J.S.A. 34:15-51 and get the case dismissed. People think they can file years later anytime, but the two-year clock is strict, so this date is the most important entry on the form.
14. Occupational Disease and Periods of Exposure
The form asks Occupational Disease: YES or NO and, if yes, to “Give Periods of Exposure.”
To answer, check NO for a sudden accident like a fall. Check YES for a condition that developed from ongoing job exposure, then list the start and end dates of that exposure.
For example, Sam Rivera, a machinist with carpal tunnel from years of repetitive work, checks YES and writes 01/2018 to 03/2026.
The edge case is hearing loss or lung disease, where the two-year clock starts when you first learn the condition is work-related, not when exposure began.
A common mistake is checking NO on a repetitive-stress claim, which can make the carrier argue your single-day “accident” never happened. People confuse occupational disease with ordinary illness, but it means a condition caused by job conditions over time.
15. Where and How the Injury Occurred
Two fields ask Where Injury Occurred (incl. town and county) and How Injury Occurred.
To answer, name the exact place including the New Jersey town and county, then describe the event in plain, factual words. Be detailed but not so narrow that you lock yourself into one theory.
For example, Maria Lopez writes “Warehouse floor, Edison, Middlesex County” and “Felt sharp low-back pain while lifting a 60-pound pallet box from the floor.”
The edge case is an injury off-site, such as a delivery route; name the actual location and county where it happened to fix jurisdiction.
A common mistake is a vague entry like “got hurt at work,” which gives the carrier room to deny that the injury arose from your job. People think more detail is risky, but a clear cause-and-body-part statement strengthens your claim.
16. Describe Extent and Character of Injury
This field says, “DESCRIBE EXTENT AND CHARACTER OF INJURY: If there has been amputation or disability to any member or impairment of any physical function, explain fully.”
To answer, list every body part affected and the type of harm, such as a herniated disc, torn rotator cuff, or amputation. List everything, even parts that hurt less.
For example, Maria Lopez writes “Lumbar spine herniation at L4-L5; radiating pain and numbness into right leg.”
The edge case is a later-discovered injury; you may amend the petition to add a body part you did not know about at filing, but listing it now avoids a fight.
A common mistake is naming only the worst injury and leaving out a secondary one, which can bar recovery for the part you omitted. People think they can add injuries freely at the hearing, but unlisted parts often draw objections.
17. Date Stopped Work and Date Returned to Work
Two fields ask Date Stopped Work and Date Returned to Work.
To answer, enter the first day you missed work because of the injury and the date you came back, if you have. Leave the return date blank if you are still out.
For example, Maria Lopez writes 02/11/2026 as the date she stopped and leaves the return date blank because she is still out.
The edge case is light-duty work; if you returned to a reduced job, enter that return date and note the restriction in the injury description.
A common mistake is listing the accident date as the stopped-work date when you actually kept working for days, which can mismatch your temporary disability period. People think any time off counts, but temporary disability benefits generally start after seven days out.
18. Date Injury Reported and To Whom
Two fields ask Date Injury Reported and Injury Reported To Whom.
To answer, enter the date you told your employer and the name and title of the person you told.
For example, Maria Lopez writes 02/10/2026 and “Reported to shift supervisor Tom Becker.”
The edge case is verbal-only notice; New Jersey allows verbal notice, but naming the supervisor and date proves you met the 90-day notice rule.
A common mistake is leaving this blank, which lets the carrier argue you never gave timely notice and can defeat the claim. People think reporting is optional once they file, but late notice past 90 days can bar benefits entirely.
19. Occupation and Type of Work
This field asks for your Occupation and Type of Work.
To answer, state your job title and a short description of your duties, focusing on the physical demands tied to your injury.
For example, Maria Lopez writes “Warehouse associate; lifts and stacks boxes up to 70 pounds.”
The edge case is a worker with mixed duties; describe the part of the job that caused the harm, which helps prove the injury arose from work.
A common mistake is a one-word title with no duties, which makes it harder to connect the injury to the job. People think the title alone is enough, but the duties show why the injury is work-related.
20. Gross Wages, Wage Period, and Compensation Paid
This block covers Gross Wages, Wage Period, Rate of Temp. Compensation, Weeks of Temp. Disability paid, Temporary Disability Paid, and Permanent Disability Paid.
To answer, enter your gross pay before deductions and the period it covers, such as weekly. Fill in any temporary or permanent amounts the carrier already paid; enter zero if none.
For example, Maria Lopez writes $960 gross wages, “Weekly” as the wage period, and $0 paid because the carrier denied her.
The edge case is variable pay with overtime or tips; use your average weekly wage over the prior weeks, since that sets your benefit rate.
A common mistake is reporting take-home pay instead of gross wages, which lowers your benefit rate and your eventual award. People think the wage figure is minor, but it directly drives the dollar value of every weekly check, capped at the state maximum, which for recent years has exceeded one thousand dollars per week per state benefit data.
21. Employer Furnished Medical Aid and Interrogatory Demands
The form asks Employer Furnished Medical Aid: YES or NO and offers two demand checkboxes for occupational disease interrogatories under [N.J.A.C. 12:235-3.8(f)] and for medical records under [N.J.A.C. 12:235-3.8(c)].
To answer, check YES if the employer authorized any treatment, or NO if it refused. Check the demand boxes to force the carrier to produce records and answers.
For example, Maria Lopez checks NO for medical aid and checks the demand box for all treatment records.
The edge case is partial treatment; if the employer paid for one ER visit but then cut you off, check YES and explain the cutoff in the facts section.
A common mistake is skipping the demand boxes, which means you must chase records yourself later. People think demanding records is aggressive, but it is a routine right that speeds up your proof.
22. Medicare and Medicaid Eligibility Questions
Three questions ask whether you are Medicare eligible or a Medicare beneficiary, whether you were eligible for Medicaid benefits at the time of the work injury, and whether you became eligible for Medicaid benefits after the work injury.
To answer, check YES or NO honestly for each. These answers protect public programs’ interests in any future settlement.
For example, Robert King, age 67, checks YES for Medicare and NO for both Medicaid questions.
The edge case is a worker who turns 65 during the case; update the Division, because Medicare may need to approve part of a settlement through a set-aside.
A common mistake is checking NO without thinking, which can stall a settlement later when the truth surfaces. People think these questions are nosy, but federal law requires Medicare’s interests be considered before a workers’ comp settlement is approved.
23. What Other Facts and Summary of Changes
The form asks “What other facts are there that you believe important” and provides a “Summary of Changes” to complete only on amended pleadings.
To answer, add anything that helps your story, such as witnesses, prior similar denials, or a second job affecting your wage. Use the Summary of Changes only when you are amending.
For example, Sam Rivera notes “Two coworkers witnessed symptoms; employer never offered treatment.”
The edge case is a new fact discovered after filing; you put it in the Summary of Changes on an amended petition rather than the original facts box.
A common mistake is filling the Summary of Changes on a first filing, which confuses the clerk. People think this box is for arguments, but it is for facts; legal arguments come later through your attorney.
24. Verification and Signature Block
The petition ends with the Petitioner signature line and a verification: “STATE OF NEW JERSEY, COUNTY OF , Subscribed and sworn or affirmed to before me this ___ day of , 20___.”
To answer, sign as the Petitioner and have the verification sworn before a notary or authorized officer who completes the county and date.
For example, Maria Lopez signs and dates the petition in front of a notary at her bank.
The edge case is electronic filing, where the e-filing system captures the verification differently, so follow the E-Filing Procedures Guide for the online oath.
A common mistake is filing without the verification completed, which makes the petition defective and subject to rejection. People think a signature alone is enough, but the law requires the petition be “filed and verified,” meaning sworn under oath.
Three Filled-Out Examples Using Real Scenarios
These three scenarios show how different workers complete the same petition based on their facts.
Scenario 1: Maria Lopez, a single traumatic warehouse injury
| Form Section | What Maria Enters |
|---|---|
| New or Amended Filing | NEW FILING |
| Petitioner Name and SSN | Maria Lopez; 123-45-6789 |
| Employer Name | Garden State Logistics LLC (DBA “GSL Warehouse”) |
| Insurance Carrier and Claim No. | Liberty Mutual; WC-4471892 |
| Employer Status | INSURED |
| Date of Accident | 02/10/2026 |
| Occupational Disease | NO |
| How Injury Occurred | Lifting a 60-pound pallet box; sharp low-back pain |
| Extent of Injury | L4-L5 herniation with right-leg numbness |
| Gross Wages | $960 weekly; $0 paid |
Scenario 2: Sam Rivera, an occupational repetitive-stress claim
| Form Section | What Sam Enters |
|---|---|
| New or Amended Filing | NEW FILING |
| Petitioner Name | Sam Rivera |
| Employer Status | UNINSURED (officers named on supplement) |
| Date of Last Exposure | 03/15/2026 |
| Occupational Disease | YES |
| Periods of Exposure | 01/2018 to 03/2026 |
| How Injury Occurred | Repetitive machine work causing carpal tunnel |
| Extent of Injury | Bilateral carpal tunnel syndrome, both wrists |
| Occupation | Machinist; repetitive gripping and pressing |
| Other Facts | Two coworkers witnessed symptoms; no treatment offered |
Scenario 3: The King family, a dependency claim after a work death
| Form Section | What the Family Enters |
|---|---|
| Form Used | Dependency Claim Petition WC-366, not WC-365 |
| Filer | Surviving spouse Donna King |
| Deceased Worker | Robert King |
| Employer Status | INSURED |
| Date of Accident | 04/02/2026 |
| How Injury Occurred | Fatal fall from scaffold at job site |
| Extent of Injury | Death resulting from workplace fall |
| Dependents | Surviving spouse and two minor children |
| Medicare/Medicaid | Answered for the dependents as required |
| Verification | Sworn before a notary by Donna King |
The King example shows the key rule that a death claim uses the Dependency Claim Petition (WC-366), while living workers like Maria and Sam use WC-365.
How to File the Completed Form
You can file Form WC-365 through two channels, and both reach the same Division.
File online through COURTS on-line. Attorneys and carriers file at the Division’s COURTS on-line portal after obtaining access credentials. There is no filing fee for the injured worker to bring a claim petition. The system assigns a case number at once, and your proof of filing is the electronic confirmation and docket number the portal generates. Processing to a first hearing notice commonly takes weeks, with a formal hearing often months out.
File by mail. Mail the completed and verified paper WC-365 to the Division of Workers’ Compensation, PO Box 381, Trenton, New Jersey 08625-0381, the address printed on the form. There is still no fee. Keep a stamped copy and your certified-mail receipt as proof of the filing date, which matters for the two-year deadline. The Division then dockets the case and mails you a case number and vicinage assignment.
For either channel, save every confirmation, because that record proves you filed in time. The Division serves the employer and carrier with the petition after docketing, and the respondent must file an Answer (Form WC-367).
What Happens After You File
Once your petition is docketed, the Division assigns a case number and a vicinage, and it serves the employer and carrier. The respondent then files an Answer, usually within about 30 days, admitting or denying your claims. From there your case is placed on a hearing calendar.
A first hearing often occurs several months after filing, and cases can stretch over a year as treatment, medical exams, and negotiations proceed. The judge can order temporary disability checks and medical treatment along the way through a Motion for Temporary and Medical Benefits (Form WC-101) if the carrier refuses. Most cases settle, ending in an approved order for a percentage of permanent disability.
If you disagree with the judge’s final decision, you can appeal to the Superior Court, Appellate Division. The Division’s order is binding and enforceable, unlike the non-binding suggestion from an informal hearing.
Mistakes to Avoid When Filling Out the Form
- Filing after the two-year deadline. A judge can dismiss your case entirely under N.J.S.A. 34:15-51.
- Writing the wrong date of accident. A mismatch with carrier records can push you outside the deadline.
- Naming the wrong employer. The true employer can argue it was never properly named and escape the case.
- Leaving the carrier claim number blank when you have it. Your petition may attach to the wrong file or sit unmatched.
- Reporting take-home pay instead of gross wages. Your weekly benefit rate drops and your award shrinks.
- Checking NO on occupational disease for a repetitive injury. The carrier can deny that a single-day accident ever happened.
- Listing only your worst injury. Body parts you leave off can be barred from the award.
- Skipping the injury-reported date and name. The carrier can claim you missed the 90-day notice rule.
- Filing without the sworn verification. The petition is defective and may be rejected.
- Using a nickname instead of your legal name. It creates mismatches with wage and medical records.
- Inventing a case number on a new filing. It confuses the clerk and delays docketing.
- Ignoring the Medicare and Medicaid questions. It can block approval of your settlement later.
Do’s and Don’ts
- Do check NEW FILING and leave the case number blank on a first petition, because the Division assigns it.
- Do name the exact legal employer and any trade name, so the right party answers.
- Do list every injured body part, since unlisted parts can be barred.
- Do report gross wages, because that figure sets your benefit checks.
- Do keep proof of filing, since it protects your deadline.
- Do complete the sworn verification, because the law requires a verified petition.
- Don’t guess the date of accident, because an error can blow the two-year deadline.
- Don’t leave contact details blank, since missed notices can lead to dismissal.
- Don’t use the Summary of Changes on a first filing, because it is only for amendments.
- Don’t skip the records-demand checkboxes, since they speed your proof.
- Don’t check INSURED when the employer had no policy, because you need the Uninsured Employers Fund route.
- Don’t file a death claim on WC-365, because survivors must use the Dependency Claim Petition.
Pros and Cons of Filing on Your Own vs. With an Attorney
| Filing Pro Se | Filing With an Attorney |
|---|---|
| Pro: No fee taken from your award, because you keep the full amount. | Pro: A lawyer names the right parties and meets deadlines, reducing dismissal risk. |
| Pro: You control the filing pace and timing yourself. | Pro: Attorney fees are paid from the award, so you owe little up front. |
| Pro: Simple, clearly accepted claims may settle without help. | Pro: Counsel can file motions to force treatment and temporary checks. |
| Con: One field error, like the wrong date, can sink the claim. | Con: A fee, often capped around 20 percent, comes out of your final award. |
| Con: You face the carrier’s lawyers without legal training. | Con: You give up some control over strategy and timing. |
| Con: You must handle records, hearings, and the sworn verification alone. | Con: Communication can feel slower while the firm handles many cases. |
Claim Petition vs. Application for an Informal Hearing
| Employee Claim Petition (WC-365) | Application for an Informal Hearing (WC-66) |
|---|---|
| Opens a formal, binding court case before a judge. | Opens an informal session for a non-binding suggestion. |
| The judge can enter an enforceable award and order benefits. | The judge’s suggestion does not bind either side. |
| Best when benefits are flatly denied or disputed. | Best for a quick nudge on a smaller disagreement. |
| Triggers a respondent Answer and full litigation. | Lighter process with less paperwork and no Answer. |
| You can still appeal the final order to the Appellate Division. | You can still file a formal Claim Petition afterward. |
Frequently Asked Questions
Do I have to file Form WC-365 if my employer is paying my benefits?
No. If the carrier voluntarily pays your medical care and lost wages, you do not need to file. You file when benefits are denied, delayed, cut off, or you want a permanent award.
Is there a deadline to file the Claim Petition?
Yes. You generally have two years from the date of injury or the last payment of compensation, whichever is later, under N.J.S.A. 34:15-51, or you can lose your right to benefits.
Is there a fee to file the petition?
No. The injured worker pays no filing fee to bring an Employee Claim Petition with the Division of Workers’ Compensation.
Do I write my SSN even if I fear immigration issues?
Yes. The form requests it for record-keeping and benefit cross-matches only, and coverage does not depend on immigration status; if you have none, check “SSN Not Available.”
Should I leave the Case No. and Vicinage blank in Box 2?
Yes. On a new filing you leave both blank, because the Division assigns your case number and district office after you file.
Do I check NEW FILING or AMENDED FILING for my first petition?
Yes, check NEW FILING. Use AMENDED FILING only when a case is already open and you are correcting or adding to it.
Do I report gross wages or take-home pay in the wage box?
Yes, report gross wages before deductions. Take-home pay understates your average weekly wage and lowers every benefit check and your final award.
Should I list every injured body part or just the worst one?
Yes, list every body part affected. Parts you leave off the petition can be barred from your eventual disability award.
Can I file the petition myself without a lawyer?
Yes. A worker may file pro se, though many hire counsel because attorney fees come out of the award and one form error can hurt the case.
Do survivors of a worker who died use Form WC-365?
No. Survivors file the Dependency Claim Petition, Form WC-366, not the Employee Claim Petition, to claim death benefits.
Does an informal hearing give me a binding decision?
No. An Application for an Informal Hearing produces only a non-binding suggestion, while the Claim Petition leads to an enforceable order.
Do I need to have the petition notarized?
Yes. The petition must be filed and verified, meaning sworn or affirmed before a notary or authorized officer, or it can be rejected as defective.
Can I add an injury or fact after I file?
Yes. You can file an amended petition and use the Summary of Changes box to add a newly discovered injury or fact, though listing it at first filing avoids disputes.
Where do I mail the paper petition?
Yes, there is a set address: the Division of Workers’ Compensation, PO Box 381, Trenton, New Jersey 08625-0381, as printed on Form WC-365.
Related reading
- How to Fill Out New York Form C-3 (w/Examples) + FAQs
- How to Fill Out Michigan WDCA Form WC-105 + FAQs
- How to Fill Out the New Jersey Division of Workers’ Comp Application for Review or Modification of Formal Award (WC-368) + FAQs
- How to Fill Out the New Jersey Division of Workers’ Comp Order Approving Settlement (+ FAQs)
- How to Fill Out the Maryland WCC Employee Claim Form (C-1) (w/ Examples) + FAQs
- How to Fill Out the Maryland WCC First Report of Injury (Form 1A-1) — With Examples + FAQs
- How to Fill Out California WCAB DWC-AD 1 (w/Examples) + FAQs