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  FREQUENTLY USED NJ FORMS  
 
    New Jersey Form Title
NJCRIB Bureau
Manual Reference
 
   
(Click to view form in PDF format)
(Click below to review the applicability and proper use of the forms.)
 
 

Acceptance of Bureau Membership and Designation

Part 1: Section 4
 
 

Acceptance of New Jersey Workers Compensation Insurance Plan

Part 1: Section 4
 
 

Application of New Jersey Construction Classification Premium Adjustment Program

Part 3: Section 8
 
 

ACORD 132NJ
(7/2013)

New Jersey Workers Compensation Insurance Plan
  Instructions and Rules

Part 3: Section 14
 
 

ACORD 133NJ
(7/2013)

New Jersey Workers Compensation Insurance Plan
  Application For Designation Of An Insurance Company

Part 3: Section 14
 
 

ACORD 134NJ
(1/2007)

New Jersey Workers Compensation Insurance Plan
  Notice Of Election - Proprietors and Partners

Part 3: Section 14
 
 

ACORD 135NJ
(09/2009)

New Jersey Workers Compensation Insurance Plan
  Client Supplemental Employee Leasing Application

Part 3: Section 14
 
 

ACORD 136NJ
(9/2009)

New Jersey Workers Compensation Insurance Plan
  Truckers Supplemental Application

Part 3: Section 14
 
 

Form 16 NJ
(4/2000)

Posting Notice

Part 3: Section 2
 
 

Form NJ LR-LD
(6th Rev)

Large Risk — Large Deductible Program
  Notice Of Election (Effective 7/1/06)

Part 3: Section 10A
 
 

Form NJRR-1
(8th Rev)

New Jersey Notice Of Election — Retrospective Rating

Part 3: Section 12
 
 

Form NJRR-2

New Jersey Notice Of Election — Retrospective Rating (Effective 1/1/05)

Part 3: Section 12
 
 

Form PP-1B

New Jersey Notice Of Election — Proprietors And Partners
  Workers Compensation and Employers Liability Insurance

Part 3: Section 2
 
 

Form #Req 11:6-2.3(d)

Application for An Approved Managed Care Program
  Premium Reduction

Part 3: Section 10B
 
 

XM1-99

Experience Rating Data Form - Front

Part 3: Section 11
 
 

Form XM1-99

Experience Rating Data Form - Back - Instructions

Part 3: Section 11
 
 

XM1-2014

Experience Rating Data Form - Front

Part 3: Section 11
 
 

Form XM1-2014

Experience Rating Data Form - Back - Instructions

Part 3: Section 11
 
 

USR-ASWG Form A

Primary Unit Statistical Reporting Form

Part 3: Section 13
 
 

ICR-ASWG

Individual Claim Report Form

Part 3: Section 13
 
 

ICR-ASWG (Back)

Individual Claim Report Form (Back)

Part 3: Section 13
 
 

Transmittal Letter
(Form TL-1)

New Jersey CRIB Hard Copy Transmittal Letter (Form TL-1)

 
 

Letter of Transmittal
(Form S-30NJ)

New Jersey - Letter of Transmittal (Form S-30NJ - tape submission only)

 
 

Letter of Transmittal
(Form S-31NJ)

New Jersey - Letter of Transmittal (Form S-31NJ)

 
 

Cancellation
(Form 116-B)

Cancellation Form (Form 116-B)

 
 

Reinstatement
(Form 117-A)

Reinstatement Form (Form 117-A)

 
 
 
 
 
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