Notice Of Motion For Temporary And Or Medical Benefits
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Notice Of 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: Notice Of Motion For Temporary And Or Medical Benefits, WC-101i, New Jersey Workers Comp, Formal Litigation
NOTICE OF MOTION FOR
TEMPORARY AND/OR
MEDICAL BENEFITS
(N.J.A.C. 12:235-3.2)
State of New Jersey
Department of Labor and Workforce Development
DIVISION OF WORKERS’ COMPENSATION
WC-101i (r-7-07)i
SOCIAL SECURITY NUMBER:
DOB:
SSN
VICINAGE:
Atlantic City
FEDERAL EMPLOYER NUMBER
NJ REG NUMBER
NAME:
ATTORNEY FOR
PETITIONER
PETITIONER
NAME:
CASE NO’S.:
ADDRESS:
ADDRESS:
TELEPHONE NUMBER (AREA CODE):
vs
NAME:
ADDRESS:
INSURANCE
CARRIER
RESPONDENT
NAME
SELF-INSURED
NOT-COVERED
CLAIM NUMBER:
ADDRESS:
TO:
(Respondent’s Attorney)
(Address)
This Motion is supported by affidavit(s) and/or certification(s) made in the personal knowledge of the:
Petitioner and/or
Petitioner’s Attorney
Petitioner alleges that:
A.
B.
Temporary Disability Benefits
Petitioner is currently totally temporarily disabled and entitled to temporary disability benefits from
continuing at the rate of $
per week. Respondent provided benefits from
through
the rate of $
per week.
and
at
Medicals
As set forth in the attached medical report(s)* of
Petitioner is currently in need of:
Medical treatment
Diagnostic studies
; and/or
Referral to a specialist(s)
* Medical report(s) must state the medical diagnosis. If the petitioner, having received treatment, cannot secure a report of
the medical provider authorized by the respondent, this may be set forth in the affidavit in lieu of the physician’s report.
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State of New Jersey
Department of Labor and Workforce Development
DIVISION OF WORKERS’ COMPENSATION
WC-101i (r-7-07)i
NOTICE OF MOTION FOR
TEMPORARY AND/OR
MEDICAL BENEFITS
(N.J.A.C. 12:235-3.2) page 2
CASE NO’S.:
VICINAGE:
Atlantic City
C.
Other Information Attached or Enclosed if available
(see attached)
Itemized bill (s) and report(s) of treating physician(s) and/or institutions for which services petitioner is seeking
payment (list here or attach).
D.
Other Evidence in Support of Motion
(list here or attach)
(see attached)
Dated:
, Attorney for Petitioner
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