Fill and Sign the Answering Statement to Form

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC-170 (r-4-06) ANSWERING STATEMENT TO MOTION FOR TEMPORARY AND/OR MEDICAL BENEFITS (N.J.A.C. 12:235-3.2) CASE NO’S.: VICINAGE: SOCIAL SECURITY NUMBER: SSN FEDERAL EMPLOYER NUMBER NJ REG NUMBER NAME: NAME: PETITIONER COUNTY OF RESIDENCE: ADDRESS: ADDRESS: vs TELEPHONE NUMBER (AREA CODE): NAME: ATTORNEY FOR RESPONDENT NAME SELF-INSURED NOT-COVERED CLAIM NUMBER; RESPONDENT COUNTY: ADDRESS: INSURANCE CARRIER 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 Tempor ary Disability Benefits for the following period: to or Weeks at $ Per week Paid Unpaid (State medical, factual and legal reasons): 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