Fill and Sign the Application to Workers Compensation Judgepdf Fpdf DOCX Form

STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION _________________________________________________, WCA No.:_______________ W ork er, v. _________________________________________________, and _________________________________________________, Employer/Insurer. APPLICATION TO WORKERS’ COMPENSATION JUDGE 1. Type of injury: ______Occupational Injury _______Occupational Disease 2. Worker’s Full Name:____________________________________________________________________ Mailing Address:_______________________________________________________________________ City/State/Zip:_________________________________________________________________________ Telephone No.: ( )___________________________________________________________________ 3. Worker’s date of birth: / / Age: ____ Sex: ____ M ____ F ____ 4. Worker’s Social Security No.: ______-______-______ 5. Full Name of Employer: ________________________________________________________ Employer’s Address: ________________________________________________________ City/State/Zip: ________________________________________________________ Telephone No.: (____)___________________________________________________ 6. Insurance Carrier: ________________________________________________________ Address: ________________________________________________________ City/State/Zip: ________________________________________________________ Telephone No.: (____)___________________________________________________ 7. Date of Accident: ________________________________________________________ a. City and County of accident:__ _____________________________________________ ________ b. Worker’s job at time of acciden t:___________________________________________ ________ c. Worker’s wages at time of accident: $_____/hour $_____/bi-weekly $_____/month $_____/year d. How did the accident occur:_______________________________________________________ e. Type of injury/diagnosis:_________________________________________________________ f. Part(s) of the body injured:________________________________________________________ g. Name and address of treating Doctor:_______________________________________________ ______________________________________________________________________________ h. First date Worker was unable to perform job duties:____________________________________ i. Date of maximum medical improvement:_____________________________________________ j. Impairment rating: _______________________ Doctor’s Name:__________________________ k. Has Worker been released to work by a Doctor? _____Yes _____No If yes, please indicate the date Worker was released to work:______________________________ l. Has Worker returned to work since the acci dent? _____Yes _____No If yes, please indicate the date Worker returned to work:_________________________________ m. Name and address of current Employer:______________________________________________ ______________________________________________________________________________ n. Highest level of school completed by Worker:_________________________________________ 8. a. This application seeks the following relief: _____ Physical Examination of Worker _____ Independent Medical Examination _____ Approval of Stipulated Reimbursement Agreement under Section 52-5-17 _____ Supplemental Compensation Order _____ Determination of: _____Bad Faith/Unfair Claims Processing ____Fraud or ____Retaliation _____ Attorney Fees, Amount: $__________________ 11.4.4.9.18. 2.H NMAC b. Why is this application being filed? (Be specific, use additional pages, if necessary.) _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 9. Is an interpreter needed for the hearings on this application? ___Yes ___No. If yes, what language? _______________________ If yes, Employer must furnish. If you have questions, call 1-800-255-7965, Adjudication Bureau. ________________________________________ __________________________________________________ Worker's Signature Attorney's Signature ________________________________________ __________________________________________________ Date Worker/Attorney's Name __________________________________________________ W ork er/A tto rn ey 's A ddre ss __________________________________________________ Worker/Attorney's City, State, Zip __________________________________________________ Worker/Attorney's Telephone & Fax Number A Summons for each adverse party shall be filed with the application if one has not been previously filed. If Worker is filing this application, an Authorization to Release Me dical Information form shall be filed with the application for Physical Examination of Worker or Independent Medical Examination only. 11.4.4.9.18. 2.H NMAC