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Fill and Sign the Justia Workers Response to Complaint New Mexico Workers Form

Fill and Sign the Justia Workers Response to Complaint New Mexico Workers Form

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Open the document and fill out all its fields.
Apply your legally-binding eSignature.
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Rev. 10/17 STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION _____________________________________________, WCA No.:____________________ Worker, v. _____________________________________________, and _____________________________________________, Employer/Insurer. WORKER'S RESPONSE TO COMPLAINT Worker, _________________________________________________, responds to Employer/Insurer's Complaint as indicated (check all that apply): ____ I was hurt on the job. ____ I am disabled . ____ I have not returned to work. ____ My doctor has not released me to return to work . ____ Employer has not provided work within my restrictions. ____ I gave notice of the accident to my employer within 15 days of the acci dent. ____ Employer has not provided adequate medical care. ____ The statute of limitations does not bar my entitlement to weekly benefits. ____ A causal link between my disability and accident has been shown to a reasonable de gree of medic al probability. ____ Other : ______________________________________ Signature ____________________________ __________ Print n ame ______________________________ ________ Address ________________________________ ______ City/State/Zip _________________________________ _____ Telephone _________________________ _______ ______ E- mail address for service

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