State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-170i (r-6-15-07)
NAME:
ANSWERING STATEMENT TO 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
ADDRESS:
ATTORNEY FOR RESPONDENT
NAME:
ADDRESS:
TELEPHONE NUMBER (AREA CODE):
vs
NAME:
RESPONDENT
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