Guardian uses this six-page packet for New Jersey temporary disability benefit claims under an employer's Guardian private plan. It follows the state's TDI claim layout: Part A for the claimant, a Part B medical certificate for the doctor, and Part C for the employer. The claimant must file within 30 days after the disability starts, and late filing can lead to denial or reduction.
The employer completes Part C and returns it to the employee, who completes Parts A and A1. The employee then gives the form to the treating provider, who completes Part B after the disability begins.
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Guardian – New Jersey TDB Claim (State of New Jersey – Temporary Disability Insurance Claim Form)
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No. Part B of NJTDBDS1 cites 12:18-1.6, which prohibits charging a fee to complete the form. The certificate is completed by the patient's doctor after the disability begins, as part of the claim under the employer's Guardian New Jersey private plan.
Guardian's instructions say the claimant must file within 30 days following the start of the disability, and late filing could result in denial or reduction. Guardian recommends submitting the employee, employer and treating provider sections together to avoid delays.
Line 12 requires the doctor's original signature, printed name and medical degree, date signed, license number and state, specialty, address and phone. A checkbox identifies residents. The doctor certifies that the statements truly describe the disability and its estimated duration.