Form WC-101I "Notice of Motion for Temporary and/or Medical Benefits" - New Jersey

What Is Form WC-101I?

This is a legal form that was released by the New Jersey Department of Labor & Workforce Development - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2007;
  • The latest edition provided by the New Jersey Department of Labor & Workforce Development;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WC-101I by clicking the link below or browse more documents and templates provided by the New Jersey Department of Labor & Workforce Development.

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Download Form WC-101I "Notice of Motion for Temporary and/or Medical Benefits" - New Jersey

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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.
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.
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) page 2
WC-101i PDF (r-3-07)
VICINAGE:
C.
Other Information Attached or Enclosed if available
(see attached)
Itemized bill (s) and report(s) of treating physician(s) and/or institutions for which services petitioner is seeking
payment (list here or attach).
D.
Other Evidence in Support of Motion
(see attached)
(list here or attach)
Dated:
Attorney for Petitioner
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