State of New Jersey Department of Labor and Workforce Development Division of Workers' Compensation PO Box 381 Trenton, New Jersey 08625-0381 WC-367 r. 5/4/2015 SOCIAL SECURITY OR IDENTIFICATION NUMBER: NAME: PETITIONER ADDRESS: RESPONDENT'S ANSWER TO CLAIM PETITION Case No.: _____________________________ Vicinage: _____________________________ ORIGINAL ANSWER ATTORNEY FOR RESPONDENT AMENDED ANSWER NAME: ADDRESS: TELEPHONE NUMBER: FAX NUMBER: VS NAME: ADDRESS: INSURANCE CARRIER or SELF-INSURED ENTITY THIRD PARTY ADMINISTRATOR NAME: ADDRESS: RESPONDENT CORRECT NAME OF RESPONDENT IF INCORRECT ON CLAIM PETITION: CARRIER CLAIM NUMBER: IN ANSWER TO CLAIM PETITION IN THIS CAUSE RESPONDENT STATES: Petitioner was in employment on date alleged in petition: YES NAME: NO Correct date of accident or exposure if incorrect on Claim Petition: ADDRESS: Arose out of and in the course of employment: YES NO Coverage was provided on date of accident or exposure: YES TPA CLAIM NUMBER: NO How and where injury or disease occurred: Nature of injury or disease: Petitioner's occupation: Wage Period: Permanent Disability: Paid Gross Wages: Date respondent had knowledge or notice of injury or disease: Rate of compensation: Weeks Temporary Paid: Date petitioner stopped work: Date returned to work: Temporary Payments continuing: YES $ $ NO Temporary disability paid: $ or being paid _________ % disability of _______________________ (# ___________weeks @ $___________________totaling $___________________) Respondent rendered aid to the petitioner: YES NO If YES, please list the individuals and/or institutions providing aid or treatment: The Respondent reserves the right to cross examine all physicians upon whom the petitioner will rely in proof of the claim Other pertinent information: Demand is hereby made for answers to standard occupational disease interrogatories [N.J.A.C. 12:235-3.8(f)] Demand is hereby made for all records of medical treatment, examinations and diagnostic studies [N.J.A.C. 12:235-3.8 (c)] See page 2 I certify that the foregoing statements made by me are true to the best of my knowledge, information and belief. _________________________________________________________ Attorney for the Respondent ___________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com