Notice Of Motion For Temporary And/or Medical Benefits

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CASE NO’S.:
NOTICE OF MOTION FOR
State of New Jersey
Department of Labor and Workforce Development
TEMPORARY AND/OR
DIVISION OF WORKERS’ COMPENSATION
MEDICAL BENEFITS
(N.J.A.C. 12:235-3.2)
WC-101i PDF (r-3-07)
VICINAGE:
SOCIAL SECURITY NUMBER:
DOB:
SSN
FEDERAL EMPLOYER NUMBER
NJ REG NUMBER
NAME:
NAME:
ADDRESS:
ADDRESS:
TELEPHONE NUMBER (AREA CODE):
vs
NAME:
ADDRESS:
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.

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