Answering Statement To Motion For Temporary And Or Medical Benefits
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Answering Statement To Motion For Temporary And Or Medical Benefits Form. This is a New Jersey form and can be use in Formal Litigation Workers Comp.
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Tags: Answering Statement To Motion For Temporary And Or Medical Benefits, WC-170, New Jersey Workers Comp, Formal Litigation
State of New Jersey
Department of Labor and Workforce Development
DIVISION OF WORKERS’ COMPENSATION
ANSWERING STATEMENT TO
MOTION FOR TEMPORARY
AND/OR MEDICAL BENEFITS
(N.J.A.C. 12:235-3.2)
WC-170i (r-6-15-07)
SSN
ATTORNEY FOR
RESPONDENT
PETITIONER
NAME:
ADDRESS:
CASE NO’S.:
VICINAGE:
FEDERAL EMPLOYER NUMBER
NJ REG NUMBER
NAME:
ADDRESS:
TELEPHONE NUMBER (AREA CODE):
vs
ADDRESS:
NAME
INSURANCE
CARRIER
RESPONDENT
NAME:
SELF-INSURED
NOT-COVERED
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
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