State of New Jersey Department of Labor and Workforce Development Division of Workers222 Compensation PO Box 381 Trenton, New Jersey 08625-0381 WC-369 r. 6/17/2015 ANSWER TO APPLICATION FOR REVIEW OR MODIFICATION OF FORMAL AWARD ORIGINAL ANSWER AMENDED ANSWER Case No.: Vicinage: PETITIONER SOCIAL SECURITY OR IDENTIFICATION NUMBER: ATTORNEY FOR RESPONDENT NAME: NAME: ADDRESS: ADDRESS: TELEPHONE NUMBER: FAX NUMBER: VS RESPONDENT NAME: INSURANCE CARRIER or SELF-INSURED ENTITY NAME: ADDRESS: ADDRESS: CORRECT NAME OF RESPONDENT IF INCORRECT ON CLAIM PETITION: CARRIER CLAIM NUMBER: TO THE DIVISION OF WORKERS222 COMPENSATION: Respondent, in answer to the Application for Review or Modification, respectfully states: THIRD PARTY ADMINISTRATOR NAME: ADDRESS: TPA CLAIM NUMBER: Permanent Disability for prior award was paid f rom: to for a total of weeks, days at $ per week, totaling $ . Temporary Benefits paid subsequent to satisfaction of prior award: to for a total of weeks, days at $ per week, totaling $ . Medical Benefits paid subsequent to satisfaction of prior award: to , totaling $ . The date of the last compensation payment was . The date of the last authorized treatment was . The factual, legal and medical reasons for denying the application are as follows: See Attached For Additional Information Demand is hereby made for all records of medical treatment, examinations and diagnostic studies [N.J.A.C. 12:235-3.8 (c)] I certify that the foregoing statements made by me are true to the best of my knowledge, information and belief. Attorney for Respondent Date American LegalNet, Inc. www.FormsWorkFlow.com