ࡱ> %` Ybjbj ;̟̟ $$$$:%?*&)))))zi,T-???????$@h.,2.$.i.i.i.9?9?o2.i.i.i.?////z$z State of New Jersey Department of Labor and Workforce Development DIVISION OF WORKERS COMPENSATION WC-101i (r-7-07)iNOTICE OF MOTION FOR TEMPORARY AND/OR MEDICAL BENEFITS (N.J.A.C. 12:235-3.2) CASE NO S.:  FORMTEXT       VICINAGE:  FORMDROPDOWN  PETITIONERSOCIAL SECURITY NUMBER:  FORMTEXT      DOB:  FORMTEXT      ATTORNEY FOR PETITIONER FORMCHECKBOX  SSN  FORMCHECKBOX  FEDERAL EMPLOYER NUMBER  FORMCHECKBOX  NJ REG NUMBER  FORMTEXT      NAME:  FORMTEXT      NAME:  FORMTEXT      ADDRESS:  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        TO:  FORMTEXT      (Respondent s Attorney)  FORMTEXT      (Address) This Motion is supported by affidavit(s) and/or certification(s) made in the personal knowledge of the:  FORMCHECKBOX  Petitioner and/or  FORMCHECKBOX  Petitioners Attorney Petitioner alleges that: A. Temporary Disability Benefits  FORMCHECKBOX  Petitioner is currently totally temporarily disabled and entitled to temporary disability benefits from  FORMTEXT       and continuing at the rate of $  FORMTEXT       per week. 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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-7-07)iNOTICE OF MOTION FOR TEMPORARY AND/OR MEDICAL BENEFITS (N.J.A.C. 12:235-3.2) page 2CASE NO S.:  REF Text1   VICINAGE:  REF Dropdown1   C. Other Information Attached or Enclosed if available (see attached)  FORMCHECKBOX  Itemized bill (s) and report(s) of treating physician(s) and/or institutions for which services petitioner is seeking payment (list here or attach).  FORMTEXT       D. 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