How to Complete the New Jersey DS-1 Temporary Disability Benefits Form

The New Jersey DS-1 form is the application you file with the Division of Temporary Disability and Family Leave Insurance to collect Temporary Disability benefits when a non-work-related illness or injury keeps you from your job. The form has three parts: you complete Parts A and B, your healthcare provider completes Part C, and the full application must reach the Division within 30 days of the first day you were unable to work.¹ Your employer does not fill out any part of the DS-1, though you can ask them for help with questions about your work schedule and earnings.²

Check First Whether Your Employer Has a Private Plan

Before you touch the DS-1, ask your Human Resources department whether your employer carries an approved private disability plan. Many New Jersey employers do. If yours is one of them, you file your claim directly with that private carrier, not through the state’s online portal or Trenton mailing address. HR can tell you which carrier to contact and how to apply.¹

This matters because sending the DS-1 to the state when you should have filed privately costs you time. The Division will forward it, but that transfer alone takes four to five weeks before the carrier even begins reviewing your claim. If you worked for several employers and your most recent one has a private plan, that plan handles the entire claim regardless of what earlier employers used.

The Three Parts of the DS-1

One of the most common filing mistakes is misunderstanding who completes which section.²

Part A asks for your personal details, a description of your disability, information about any other benefits you receive, and your signature.
Part B asks about your recent employers, work schedule, and earnings.
Part C is the medical certificate, filled out entirely by your healthcare provider.

Filling Out Part A

Part A asks for your Social Security number, full name, home address, and contact information. You then describe your disability: the first date you were unable to work, the nature of the condition, and whether you have recovered or returned to work. If you’re still out, leave the recovery date blank.²

Part A also asks whether you are receiving or have applied for any other benefits, such as workers’ compensation, unemployment insurance, or paid sick leave from your employer. Answer this honestly. The Division cross-checks other state benefit programs, and discrepancies can delay or disqualify your claim. You sign and date Part A to certify that everything on it is accurate.

Filling Out Part B

Part B collects details about your recent work. For each employer you worked for during the six months before your disability started, you need the employer’s name, address, your regular weekly earnings, and your normal work schedule. If you held multiple jobs, list all of them.² Have a recent pay stub in front of you. It makes the section faster and reduces errors. The Division uses this information to verify your eligibility and to calculate your weekly benefit amount.

Getting Part C From Your Healthcare Provider

Part C holds up more claims than any other part of the form. A physician, dentist, podiatrist, chiropractor, or other licensed practitioner must complete and sign it. The section asks for your diagnosis, the date you first sought treatment, an estimated recovery date, and whether you can perform any type of work during your recovery.²

If you file online, you’ll receive a unique Online Form ID after completing Parts A and B. Give that number to your provider so their office can submit Part C through the state’s online system rather than on paper.¹ Don’t wait for a follow-up appointment. The 30-day filing deadline applies to the entire application, including the medical certification. Call your provider’s office as soon as you finish your parts and ask them to complete Part C promptly.

How and Where to Submit the Form

You have three submission options: online, by mail, or by fax. The online portal at secure.dol.state.nj.us/tdi/TDIIntroduction.aspx is the fastest. You create an account or log into an existing one, complete Parts A and B on screen, and print instructions with your Online Form ID to hand to your healthcare provider. Some applicants are asked to verify their identity through ID.me after submitting. If that happens, you’ll get an email from noreply@dol.nj.gov with instructions.¹

To file by mail, send the completed form to:

Division of Temporary Disability and Family Leave Insurance
PO Box 387
Trenton, NJ 08625-0387³

You can also fax the completed form to (609) 984-4138.

The 30-Day Deadline

Whichever method you choose, the entire application, including Part C from your provider, must reach the Division within 30 days of the first day you were unable to work. If the form arrives late, you’ll need to explain the delay, and your benefits may be reduced or denied.² This is why coordinating with your provider early matters: a late Part C makes the whole application late.

What Happens After You File

Your application enters a queue and is reviewed in the order it was received. The wait for a claims reviewer can take a few weeks.⁴ During the review, the Division may contact your healthcare provider or employers to verify information. When the review is done, you’ll receive a Notice of Eligible Determination (form D10) by mail stating whether your claim was approved, your weekly benefit amount, and the duration of your benefit period.

If your disability continues beyond the recovery date your provider originally estimated, the Division will send you a P-30 form (Request for Continued Claim Information). Your healthcare provider must complete and sign it, and you should return it promptly. Failing to do so will suspend your payments. You can submit the P-30 online if you received it by mail and have the unique Form ID number printed on it.⁵

If Your Claim Is Denied

You have 21 calendar days from the mailing date on the decision notice to file a written appeal. The appeal must include your name, Social Security number, address, and signature. Fax it to (609) 984-4138 or mail it to the Division at the same PO Box 387 address in Trenton.⁶

If the issue can’t be resolved without a hearing, the case moves to an appeal tribunal and you’ll receive a separate notice with hearing instructions. Hearings are conducted by telephone. You must register by 3 p.m. the business day before the hearing date. You can have an attorney or witnesses on the call. Have your medical records and claim paperwork organized before the hearing, because this is your chance to present evidence directly. The tribunal mails its decision afterward, along with instructions for further appeal if you disagree.

If you miss the 21-day deadline, you can still file, but you’ll need to explain the delay. An appeals examiner will decide whether to accept the late filing based on your reason.

1
Division of Temporary Disability and Family Leave Insurance. Temporary Disability Insurance
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New Jersey Department of Labor and Workforce Development. DS-1 New Jersey Temporary Disability Benefits Application
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Division of Temporary Disability and Family Leave Insurance. Contact Us
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Division of Temporary Disability and Family Leave Insurance. What Happens After I Apply?
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My Leave Benefits. Want to Extend or End Your Claim?
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New Jersey Department of Labor and Workforce Development. Appealing a Decision