State of New Jersey
State of New Jersey
Department of Labor and Workforce Development
DIVISION OF WORKERS’ COMPENSATION
WC-170i (r-6-15-07) |ANSWERING STATEMENT TO MOTION FOR TEMPORARY AND/OR MEDICAL BENEFITS
(N.J.A.C. 12:235-3.2)
|CASE NO’S.:
| |
| | |VICINAGE: |
|PETIT|NAME: |ATTORN| SSN FEDERAL EMPLOYER NUMBER NJ REG NUMBER |
|IONER| |EY FOR| |
| | |RESPON| |
| | |DENT | |
| |ADDRESS: | |NAME: |
| | | | |
| | | |ADDRESS: |
| | | | |
| | | | |
| |vs | |TELEPHONE NUMBER (AREA CODE): |
|RESPO| | | |
|NDENT| | | |
| |NAME: | | |
| | | | |
| |ADDRESS: |INSURA|NAME |
| | |NCE |SELF-INSURED NOT-COVERED |
| | |CARRIE| |
| | |R | |
| | | |CLAIM NUMBER; |
| | | | |
| | | |ADDRESS: |
| | | | |
| | | | |
| | | | |
RESPONDENT: In answer to Petitioner’s Notice of Motion for Temporary and Medical Benefits, respectfully states:
| |That Petitioner is not entitled to Temporary Disability Benefits. (State medical, factual and legal reasons): |
| | |
| | |
| |That Petitioner is only entitled to Temporary Disability Benefits for the following period: |
| | |to | |or | |Weeks at $ | |Per week Paid Unpaid |
| |(State medical, factual and legal reasons): |
| | |
| | |
| |That Petitioner is not entitled to the medical treatment requested. (State medical, factual and legal reasons and attach pertinent reports, affidavits or |
| |certification): |
| | |
| | |
|Dated: | | | |
| | | | |
| | | |Attorney for Respondent |
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