Free PDF - New Jersey

Vicinage PETITIONER CARRIER

NEW JERSEY DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF WORKERS' COMPENSATION
_ PRE-TRIAL MEMORANDUM Date RESPONDENT _ CLAIM PETITION NUMBER _

_

_

STIPULATIONS: (FILL IN) Date of Accident Compensation Paid:
Temporary Disability from Pennanent Disability percentage

Wages

Rate

_

to Member

Rate Rate

_
_


o Employment 0 Wages 0 Rate o Injuries 0 Alise out of Employment
OTHER ISSUES: Medical Bills Outstanding

CHECK IF AT ISSUE:

0 0

Accident 0 Notice In course of Employment

0 0

Exposure Temporary

0 0

Knowledge 0 Causal Relationship Nature and ex'tent of Permanent Injury

_

T.D.B. Paid FURTHER STIPULATIONS: WITNESSES: DOCTOR'S NAME PET. RESP. PET. RESP. PET. RESP. PET.
RESP.

Liens

_

DATE OF EXAMINATION

EST

TESTIMONY REQUIRED

0 0 0 0 0 0 0 0 0 0 0 0 0 0
_

PET.
RESP.

PET. RESP. PET. RESP.

Videos or other electronic media to be introduced at trial: (list witnesses under "OTHER WTINESSES" below)

OTHER WITNESSES: Tlial time of petitioner

Petitioner _

Respondent Trial time of respondent

_ _

Attorney for Petitioner

Attorney for Respondent

Judge of Compensation
WC(OO)-31 (R-6-07)

Recommendation

I