State of New Jersey Department of Labor and Workforce Development Division of Workers' Compensation PO Box 381 Trenton, NJ 08625-0381 SOCIAL SECURITY NUMBER: RESPONDENT'S ANSWER TO APPLICATION FOR MEDICAL PROVIDER CLAIM PETITION ANMCP (r. 7/7/10) Case No.: _________________________ Vicinage: _________________________ FEDERAL EMPLOYER IDENTIFICATION NUMBER: NAME: INJURED WORKER NAME: ADDRESS: ATTORNEY FOR RESPONDENT ADDRESS: TELEPHONE NUMBER: FAX NUMBER: FEDERAL EMPLOYER IDENTIFICATION NUMBER: NAME: SELF-INSURED NOT-COVERED APPLICANT NAME: ADDRESS: INSURANCE CARRIER Vs ADDRESS: CLAIM NUMBER: NAME: RESPONDENT ADDRESS IN ANSWER TO MEDICAL PAYMENT APPLICATION, RESPONDENT STATES: Injured Worker has has not filed a Workers' Compensation Claim Petition related to this injury. Claim Petition Number : NO Is there a contractual rate for reimbursement for this medical provider? YES Injured worker was in employment on date alleged in petition: YES NO Correct date of accident if incorrect on Application: Coverage was provided on date of accident or exposure: YES NO Accident arose out of and in the course of employment: YES NO How and where injury or disease occurred: Nature of injury or disease: Injured worker's occupation: Treatment for which payment is sought was authorized: YES NO Date respondent had knowledge or notice of injury or disease: Other pertinent information: I certify that the foregoing statements made by me are true to the best of my knowledge, information and belief. See Attached For Additional Information _________________________________________________________ Attorney for the Respondent ___________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com