Fill and Sign the Employers Response to Workers Compensation Complaint New Mexico Form

STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION __________________________________________, WCA No.:___________________ Worker, v. __________________________________________, and __________________________________________, Employer/Insurer. RESPONSE Employer, by and through Attorney/Representative____________________________________________, responds to Worker’s complaint as indicated (check all that apply): 1. _____ The Worker was not hurt on the job. 2. _____ The Worker is not disabled. 3. _____ Actual or written notice of the accident was not received within ___days. 4. _____ Employer has provided adequate medical care. 5. _____ The Worker has not complied with the law regarding the selection of a health care provider. 6. _____ The statute of limitations bars the Worker’s complaint for weekly compensation benefits. 7. _____ A causal link between disability and accident has not been shown to a reasonable medical probability. 8. _____ The Worker sustained a scheduled injury. 9. _____ (Other): ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ _________________________________________ Signature ________________________________________ Attorney/Representative I certify a copy of the _______________________________________ Response was mailed to Address each opposing party ________________________________________ this date City/State/Zip (____)______________ (____)______________ ______________________________________ Telephone & Fax Number _______________________________________ (Signature of Party mailing Response.) 11.4.4.9.18.2.E NMAC