Form Wc-369 Answer To Application For Review Or Modification Of Formal Award
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1ANSWER TO
State of New Jersey
Case No.: _____________________________
Department of Labor and Workforce Development
APPLICATION FOR REVIEW OR
Division of Workers’ Compensation
MODIFICATION OF FORMAL AWARD
PO Box 381
Vicinage:
_____________________________
Trenton, New Jersey 08625-0381
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ORIGINAL ANSWER
AMENDED ANSWER
WC-369 r. 6/17/2015
SOCIAL SECURITY OR IDENTIFICATION NUMBER:
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE NUMBER:
FAX NUMBER:
VS
NAME:
NAME:
ADDRESS:
ADDRESS:
CORRECT NAME OF RESPONDENT IF INCORRECT ON CLAIM PETITION:
CARRIER CLAIM NUMBER:
NAME:
ADDRESS:
TO THE DIVISION OF WORKERS’ COMPENSATION:
Respondent
in answer to the Application for Review
,
TPA CLAIM NUMBER:
or Modification, respectfully states:
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:
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See Attached For Additional Information
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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
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