Compensation Presently Payable Under: Notice of Compensation Payable Agreement Supplemental Agreement Award ANSWER TO PETITION FOR COMMUTATION EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER -- WCAIS CLAIM NUMBER --DATE OF INJURY MM DD YYYY Name Address Address City/Town State ZIP County Telephone FEIN Name Address Address City/Town State ZIP County Telephone FEIN Contact NAIC code or Insurer code Insurer/TPA claim # First name Last name Date of birth EMPLOYEE EMPLOYER VS. INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) INJURY INFORMATION Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease Provide the following information if Employer has accepted liability for this injury: DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION TO YOUR HONORABLE JUDGE:002 In answer to the petition presented to your Honorable Judge by002 requesting commutation of future installments of compensation payable in the captioned case, (I)(we) submit for your consideration the following facts: American LegalNet, Inc. www.FormsWorkFlow.com (I)(we) further submit for your consideration the following additional facts: For the above reasons, (I)(we) request that your Honorable Judge the said petition for commutation in the captioned case. WHEREFORE, the respondent requests that the petition be dismissed or in the alternative disallowed. NClaims Information Services. PLEASE ENTER MY APPEARANCE FOR RESPONDENT: PA Attorney ID number Firm name Address Address MM DD YYYY City/Town State ZIP Telephone (typed/printed) (typed/printed) -- Employer Information Claims Information Services Email Services Hearing Impaired *35*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com