Notice Of Motion For Temporary And Or Medical Benefits {WC-101i}

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-101i (r-3-06) SOCIAL SECURITY NUMBER: NOTICE OF MOTION FOR TEMPORARY AND/OR MEDICAL BENEFITS (N.J.A.C. 12:235-3.2) SSN CASE NO'S.: VICINAGE: FEDERAL EMPLOYER NUMBER NJ REG NUMBER PETITIONER NAME: DOB: NAME: COUNTY OF RESIDENCE: ATTORNEY FOR PETITIONER ADDRESS: ADDRESS: vs NAME: TELEPHONE NUMBER (AREA CODE): COUNTY: RESPONDENT NAME SELF-INSURED NOT-COVERED INSURANCE CARRIER ADDRESS: CLAIM NUMBER: ADDRESS: TO: (Respondent's Attorney) (Address) This Motion is supported by affidavit(s) and/or certification(s) made in the personal knowledge of the: Petitioner and/or Petitioner alleges that: A. Temporary Disability Benefits Petitioner is currently totally temporarily disabled and entitled to temporary disability benefits from _____________ and continuing at the rate of $ ___________ per week. Respondent provided benefits from ________________ through _________________ at the rate of $____________ per week. B. Medicals As set forth in the attached medical report(s)* of Petitioner is currently in need of: Medical treatment Diagnostic studies Referral to a specialist(s) ; and/or Petitioner's Attorney * Medical report(s) must state the medical diagnosis. If the petitioner, having received treatment, cannot secure a report of the medical provider authorized by the respondent, this may be set forth in the affidavit in lieu of the physician's report. American LegalNet, Inc. www.FormsWorkflow.com State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-101i (r-3-06) NOTICE OF MOTION FOR TEMPORARY AND/OR MEDICAL BENEFITS (N.J.A.C. 12:235-3.2) page 2 CASE NO'S.: VICINAGE: C. Other Information Attached or Enclosed if available (see attached) Itemized bill (s) and report(s) of treating physician(s) and/or institutions for which services petitioner is seeking payment (list here or attach). D. Other Evidence in Support of Motion (list here or attach) (see attached) Dated: Attorney for Petitioner American LegalNet, Inc. www.FormsWorkflow.com