Answer To Petition To {LIBC-377}

DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION ANSWER TO PETITION TO/FOR:002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Address Address City/Town State ZIP County Telephone INJURY INFORMATION Provide the following information if Employer has accepted liability for this injury: Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease DATE OF INJURYWCAIS CLAIM NUMBER - - MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN VS. INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN NAIC code or Insurer code Insurer/TPA claim # TO YOUR HONORABLE JUDGE: In answer to the following petition(s): Joinder of additional defendant In the above case, the respondent respectfully pleads as follows: (Answer in numerical order in response to corresponding numbers on petitions.) American LegalNet, Inc. www.FormsWorkFlow.com Compensation presently payable under: Notice of compensation payable Agreement Supplemental agreement Award Additional information: WHEREFORE, the respondent requests that the petition be dismissed or in the alternative disallowed. N PLEASE ENTER MY APPEARANCE FOR RESPONDENT: Attorney222s name PA Attorney ID number MM DD YYYY Firm name Address Address City/Town State ZIP Telephone Attorney222s signature Attorney222s name (typed/printed) Respondent222s signature Respondent222s name (typed/printed) -- *377*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com