Free New Jersey Department of - New Jersey

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS' COMPENSATION WC-7 (12-07 interactive)

CASE NO'S.:

NOTICE OF MOTION
VICINAGE:
TAX IDENTIFICATION NUMBER

NAME:

PETITIONER

ADDRESS:

ATTORNEY FOR PETITIONER

NAME: ADDRESS:

vs
RESPONDENT
NAME:

TELEPHONE NUMBER (AREA CODE):

INSURANCE CARRIER

ADDRESS:

NAME :

SELF-INSURED

NOT-COVERED

ADDRESS:

ATTORNEY FOR RESPONDENT

NAME: ADDRESS:

CLAIM NUMBER:

TELEPHONE NUMBER (AREA CODE):

TO:
(ADDRESS)

Please take Notice that on a date to be set by the Court, the undersigned will move for the following relief:

Movant will rely upon the following in support of this motion:

Dated: Attorney for