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Answering Statement To Motion For Temporary And Or Medical Benefits WC-170 - New Jersey
| Answering Statement To Motion For Temporary And Or Medical Benefits Form. This is a New Jersey form and can be used in Formal Litigation Workers Comp . |
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State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-170 (r-4-06) SOCIAL SECURITY NUMBER: ANSWERING STATEMENT TO MOTION FOR TEMPORARY AND/OR MEDICAL BENEFITS (N.J.A.C. 12:235-3.2) SSN CASE NO'S.: VICINAGE: NJ REG NUMBER FEDERAL EMPLOYER NUMBER PETITIONER NAME: NAME: ATTORNEY FOR RESPONDENT COUNTY OF RESIDENCE: ADDRESS: ADDRESS: vs NAME: TELEPHONE NUMBER (AREA CODE): RESPONDENT COUNTY: ADDRESS: NAME SELF-INSURED NOT-COVERED INSURANCE CARRIER 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 (State medical, factual and legal reasons): Weeks at $ Per week Paid Unpaid 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 American LegalNet, Inc. www.FormsWorkflow.com
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