How to Fill Out and Submit Form DS-1: NJ Temporary Disability Insurance

To fill out Form DS-1, New Jersey’s Temporary Disability Insurance application, you complete Parts A and B with your personal and employment information, your healthcare provider completes Part C with the medical certification, and the whole form is submitted to the Division of Temporary Disability and Family Leave Insurance within 30 days of the first day you could not work.¹ You can file online, by fax, or by mail, but only through one of those channels.

Check Whether You’re on the State Plan First

The DS-1 and the state’s online portal are only for State Plan claims. Most New Jersey employers default to the State Fund, but some carry coverage through an approved Private Plan with a private insurance carrier. If you’re on a Private Plan, your employer’s carrier handles the claim and will give you different paperwork; sending a DS-1 to the Division in that situation delays everything. Ask your HR department which plan covers you before you start.²

What to Gather Before You Open the Form

Missing information is one of the most common reasons claims get held up or denied, so pull everything together before you start.¹ You’ll need:

Your Social Security number, date of birth, and current contact information.
The exact date you became disabled, meaning the first day you could not perform your job duties.
An employment history covering the last 18 months: dates worked, employer names, the addresses where you actually worked, and each employer’s contact information.
Each employer’s Federal Employer Identification Number (FEIN), which appears on your most recent W-2 or can be obtained from HR.
Contact information for the healthcare provider who treated you within 10 days of your first day of disability.
Dates of any emergency room visits, urgent care visits, or hospitalizations.
Dates and amounts of any paid time off or other benefits you’ve received since your last day of work.
Your expected return-to-work date, or the actual date if you’ve already gone back.

Use real dates in every date field. The form instructions specifically warn against writing “present” or “current.”¹ One more thing worth knowing: it is illegal in New Jersey for anyone to charge you a fee to help complete this form.

Part A: Your Personal Information

Part A collects your identifying details: name, Social Security number, address, date of birth, and the date your disability began. It also asks about any other income or benefits you’re receiving during the disability period, including paid time off from your employer. Answer every question. If you’re filing on paper, write legibly and put your name and Social Security number on every page of the application and every attachment you include.¹

Part B: Employment Information

Part B asks about every employer you’ve worked for in the last 18 months. For each one, enter the employer’s name, address, your dates of employment, and the Federal Employer Identification Number. The standard form has space for two employers. If you had more than two during that period, make a photocopy of Part B, fill it out for each additional employer, and attach the extra pages to your application.¹

Part C: The Medical Certification

Your healthcare provider fills out Part C. They confirm the nature of your disability and the period during which you cannot work. Even though the provider does the writing, getting Part C submitted is your responsibility, not theirs.²

How Part C reaches the Division depends on how you filed Parts A and B:

If you filed online, the portal issues a unique Online Form ID once you finish your sections. Give that ID to your provider so they can submit their certification through the same system electronically. You have 14 days to go back and print the instructions page with that ID if you don’t have access to a printer when you file, so save or screenshot it either way.
If you filed on paper, your provider completes Part C on the same physical form, and the whole package goes to the Division together by fax or mail.

One practical note on timing. Under N.J.A.C. 12:18-3.2, benefits are payable from the first day of your disability only if you received medical care within 10 days of that day. If your first visit came later, benefits start from the day treatment began instead.³ That same visit is what your provider will reference in Part C, so the sooner you were seen, the cleaner the certification.

How to Submit the DS-1

Pick one of three channels. Sending the same claim through more than one does not speed anything up and actually slows processing.¹

Online, at myleavebenefits.nj.gov. This is the fastest route. The system walks you through each section and generates the Online Form ID your provider needs.²
By fax, to 609-984-4138. Send all three completed parts together.
By mail, to Division of Temporary Disability Insurance, PO Box 387, Trenton, NJ 08625-0387.⁴

If you already filed online, don’t also mail or fax a paper copy.

The 30-Day Filing Deadline

You have 30 days from the first day of your disability to file. You can start the application on or after that first date; there’s no need to wait until you’ve recovered.¹ A late claim is not automatically dead, but you’ll have to explain the delay, and the Division has the authority to reduce or deny benefits based on how late the application arrives. Treat the deadline as firm.

While you’re receiving benefits, report any return to work to the Division right away. Not doing so creates an overpayment the Division will eventually demand back, sometimes long after the fact.¹

If Your Claim Is Denied

You have 21 calendar days from the mailing date of the decision notice to appeal. You can file the appeal online, by fax to 609-984-4138, or by mail to the same PO Box 387 address in Trenton. A written appeal must include your name, Social Security number, address, and signature.⁵

A Division representative may contact you for more information before the case goes further. If the matter can’t be resolved informally, it moves to an appeal tribunal for a telephone hearing, and you’ll get a separate mailed notice with registration instructions. Register no later than 3 p.m. on the business day before the hearing. If you miss the 21-day window, you can still file, but you’ll need to explain why it’s late and an examiner decides whether to hear it.⁵

1
NJ.gov. DS-1 New Jersey Temporary Disability Benefits Application
2
NJ.gov. Division of Temporary Disability and Family Leave Insurance
3
Legal Information Institute. New Jersey Code 12:18-3.2 – Notice and Proof of Disability
4
NJ.gov. Division of Temporary Disability and Family Leave Insurance – Contact
5
NJ.gov. Division of Temporary Disability and Family Leave Insurance – Appeals