Fill and Sign the Social Security or Identification Number Form

State of New Jersey Department of Labor and Workforce Development Division of Workers’ Compensation PO Box 381 Trenton, New Jersey 08625-0381 WC-369 r. 6/17/2015 ANSWER TO APPLICATION FOR REVIEW OR MODIFICATION OF FORMAL AWARD □ ORIGINAL ANSWER □ AMENDED ANSWER Case No.: _____________________________ Vicinage: _____________________________ PETITIONER SOCIAL SECURITY OR IDENTIFICATION NUMBER: ATTORNEY FOR RESPONDENT NAME: NAME: ADDRESS: ADDRESS: TELEPHONE NUMBER: FAX NUMBER: VS RESPONDENT NAME: INSURANCE CARRIER or SELF-INSURED ENTITY NAME: ADDRESS: ADDRESS: CORRECT NAME OF RESPONDENT IF INCORRECT ON CLAIM PETITION: CARRIER CLAIM NUMBER: TO THE DIVISION OF WORKERS’ COMPENSATION: Respondent , in answer to the Application for Review or Modification, respectfully states: THIRD PARTY ADMINISTRATOR NAME: ADDRESS: TPA CLAIM NUMBER: Permanent Disability for prior award was paid from: _____________ to _____________ for a total of ______ weeks, ______ days at $ _________ per week, totaling $ __________________. Temporary Benefits paid subsequent to satisfaction of prior award: _____________ to _____________ for a total of ______ weeks, ______ days at $ _________ per week, totaling $ __________________. Medical Benefits paid subsequent to satisfaction of prior award: _____________ to _____________, totaling $ __________________. The date of the last compensation payment was _____________. The date of the last authorized treatment was _______________. The factual, legal and medical reasons for denying the application are as follows: □ See Attached For Additional Information □ Demand is hereby made for all records of medical treatment, examinations and diagnostic studies [N.J.A.C. 12:235-3.8 (c)] I certify that the foregoing statements made by me are true to the best of my knowledge, information and belief. _________________________________________________________ ___________________________ Attorney for Respondent Date