Free State of New Jersey - New Jersey

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