Fill and Sign the Nj Workers Compensation 497319695 Form

State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC-101i (r-3-07)i NOTICE OF MOTION FOR TEMPORARY AND/OR MEDICAL BENEFITS (N.J.A.C. 12:235-3.2) CASE NO’S.:       VICINAGE: PETITIONER SOCIAL SECURITY NUMBER:       DOB:       ATTORNEY FOR PETITIONER SSN FEDERAL EMPLOYER NUMBER NJ REG NUMBER       NAME:       NAME:       ADDRESS:       ADDRESS:       RESPONDENT vs TELEPHONE NUMBER (AREA CODE):       NAME:       ADDRESS:       INSURANCE CARRIER 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. Temporary Disability Benefits Petitioner is currently totally temporarily disabled and entitled to temporary disability benefits from       and continuing at the rate of $       per week. Respondent provided benefits from       through       at the rate of $       per week. B. 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. State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS’ COMPENSATION WC-101i (r-3-07)i NOTICE OF MOTION FOR TEMPORARY AND/OR MEDICAL BENEFITS (N.J.A.C. 12:235-3.2) page 2 CASE NO’S.: Error: Reference source not found VICINAGE: Error: Reference source not found 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 (see attached) (list here or attach)       Dated:             , Attorney for Petitioner