ࡱ> ikh#` ";bjbj ;X\01 ta/c/c/c/c/c/c/$0hf3d/Em!m!m!//###m!:a/#m!a/##r'-) `Q!)M,/00)3!3-)3-)  " #  //# 0m!m!m!m!$ State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS COMPENSATION WC-170i (r-6-15-07)ANSWERING STATEMENT TO MOTION FOR TEMPORARY AND/OR MEDICAL BENEFITS (N.J.A.C. 12:235-3.2) CASE NO S.:  FORMTEXT       VICINAGE:  FORMDROPDOWN  PETITIONERNAME:  FORMTEXT      ATTORNEY FOR RESPONDENT FORMCHECKBOX  SSN  FORMCHECKBOX  FEDERAL EMPLOYER NUMBER  FORMCHECKBOX  NJ REG NUMBER  FORMTEXT      ADDRESS:  FORMTEXT      NAME:  FORMTEXT      ADDRESS:  FORMTEXT        RESPONDENTvsTELEPHONE NUMBER (AREA CODE):  FORMTEXT      NAME:  FORMTEXT      ADDRESS:  FORMTEXT       INSURANCE CARRIERNAME  FORMCHECKBOX  SELF-INSURED  FORMCHECKBOX  NOT-COVERED  FORMTEXT      CLAIM NUMBER;  FORMTEXT      ADDRESS:  FORMTEXT     : z ɽɱp^RFhbh8G5CJaJhNG h8G5CJaJ"jh$*CJUaJmHnHu#jhchcCJUaJhch8GCJaJjhch8GCJUaJh#h8G5CJaJh8G5CJaJh fh8G5CJaJhbh8G5CJaJh8G5CJaJh#h8GCJaJhCJaJhXCJaJh8GCJaJh#h8GCJaJ(z  $Ifgdc $$Ifa$gdc $$Ifa$gd8G $Ifgd8G ";    J tk_k $$Ifa$gdc $Ifgdckdt$$Ifl4Fjz>+0+    4 laytc      & ( D F H L N d p r ǽ֜{ue{U{J>h8Gh5CJaJh8Gh|:CJaJjhXUaJmHnHujhXhXUaJ hXaJjhXUaJh8GhXCJ aJh8Gh|:5CJaJh#h1CJaJjGh$*h$*UaJ h8GaJjh8GUaJh#h8GB*CJaJphh8GCJaJh#h8G5CJaJh#h8GCJaJh#h8GCJaJJ L N d p tr^UUAA$q$If]q^a$gdX $IfgdX$qq$If]q^qa$gdkd1$$Ifl4Fjz>+0+    4 laytc   $ & ( * l n μٱΔٱ΂ٱul\uLujh$*UaJmHnHujh?xhpUaJh?xhPraJjh?xhPrUaJ#j`h$*h$*CJUaJ#jh$*h$*CJUaJh8Gh|:CJ aJh8Gh|:CJaJ#jxh$*h$*CJUaJh8Gh0CJaJjh8Gh0CJUaJh8Gh|:CJaJh8Gh f5CJaJ & ( t`WNB $$Ifa$gd $Ifgd|: $IfgdX$qq$If]q^qa$gdukdL$$Ifl4+\ *zP+4 laf4 $Ifgd dt$Ifgd    " $ & ( 4 6 J L N X Z \ ` b d v x Ĵʤʙĉʤ~nʤ~ch8Gh%CJaJj1 hXhXUaJh8GhXCJaJjhXhXUaJhXhXCJaJjhXUaJmHnHujIhXhXUaJ hXaJjhXUaJh8GhXCJ aJh8GhXCJaJh8Gh|:CJaJh8Gh|:CJaJ"( 4 \ ^ ` b d v }i`T` $$Ifa$gd $Ifgd|:$qq$If]q^qa$gdxkd5$$Ifl4=\ *z`P+4 laf4ytX $Ifgd  0 }l`` $$Ifa$gdqq$If]q^qgdxkd $$Ifl4{\ *z P+4 laf4ytX $Ifgd   " , . 0 4 @ B V X Z d f h j l p ӻӈre\LjG h?xhcUaJh?xh8GaJjh?xh8GUaJj h?xh?xUaJ h?xaJjh?xUaJjh$*UaJmHnHuj h?xh%UaJh?xh%aJjh?xh%UaJh8Gh%CJaJh8Gh%CJ aJh8Gh%CJaJh8Gh%5CJaJh8GhO(CJaJ0 2 4 @ h j l ull`l $$Ifa$gd $Ifgd$qq$If]q^qa$gdukd $$Ifl4F\ *zP+4 laf4l n p RullllXL dt$Ifgd8G$qq$If]q^qa$gd% $Ifgd $qq$If]q^qa$gdukdd $$Ifl44\ *zP+4 laf4 n "RThjlvxz̵̦~̦l~b\Lbbjh?xh?xUaJ h?xaJjh?xUaJ#j%h$*h$*CJUaJh8Gh%CJaJ#j h$*h$*CJUaJh8Gh8GCJaJjh8Gh8GCJUaJh8Gh:CJ aJh8Gh%5CJaJh8Gh%CJ aJh8Gh%CJaJjh$*UaJmHnHujh?xh8GUaJRz|~}i`i`` $Ifgd$qq$If]q^qa$gdxkd$$Ifl4F\ *z`P+4 laf4yt+m6 $Ifgd8Gz|444 4 444444404244445ݴԤݴݗxmf h:hO(jh:hO(U h:hJYh:hA$5h:h f5h1CJaJh8Gh%CJaJUjh?xhcUaJjh$*UaJmHnHujh?xhcUaJh?xh8GaJjh?xh8GUaJh8Gh%CJ aJh8Gh%CJaJ$4 4 4ulucccl $Ifgd), $Ifgd$qq$If]q^qa$gdukd$$Ifl44\ *z P+4 laf4    RESPONDENT: In answer to Petitioner s Notice of Motion for Temporary and Medical Benefits, respectfully states:  FORMCHECKBOX That Petitioner is not entitled to Temporary Disability Benefits. (State medical, factual and legal reasons):  FORMTEXT        FORMCHECKBOX That Petitioner is only entitled to Temporary Disability Benefits for the following period:  FORMTEXT      to FORMTEXT      or FORMTEXT      Weeks at $ FORMTEXT      Per week  FORMCHECKBOX  Paid  FORMCHECKBOX  Unpaid(State medical, factual and legal reasons):  FORMTEXT        FORMCHECKBOX That Petitioner is not entitled to the medical treatment requested. 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