Form WC-369 "Answer to Application for Review or Modification of Formal Award" - New Jersey

What Is Form WC-369?

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 June 17, 2015;
  • 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 printable version of Form WC-369 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-369 "Answer to Application for Review or Modification of Formal Award" - New Jersey

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ANSWER 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
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:
See Attached For Additional Information
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
ANSWER 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
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:
See Attached For Additional Information
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