Fill and Sign the New Mexico Compensation Form

STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINI STRATION _____________________________________________, WCA No.:____________________ Worker, v. _____________________________________________, and _____________________________________________, Employer/Insurer. APPLICATION TO WORKERS’ COMPENSATION JUDGE 1. Type of injury: ____ Accidental Work Injury ____ Occupational Disease 2. Worker’s Full Name: ___________________________________________________________________ 3. Mailing Address: ______________________________________________________________________ City/State/Zip: _______________________________________________________________________ Telephone: __________________________________________________________________________ E-mail Address for service: _____________________________________________________________ Worker’s highest level of school completed: _______________________________________________ Worker’s date of birth: ______________________ Age: _____ Sex: ____ M ____ F Worker’s Social Security No.: _____________ 4. Full Name of Employer: ________________________________________________________________ Employer’s Address: __________________________________________________________________ City/State/Zip: _______________________________________________________________________ Telephone: __________________________________________________________________________ Email Address for service: ______________________________________________________________ 5. Insurance Carrier: ____________________________________________________________________ Rev. 10/17 1 11.4.4.9 NMAC Address: ____________________________________________________________________________ City/State/Zip: _______________________________________________________________________ Telephone: __________________________________________________________________________ E-mail Address for service: _____________________________________________________________ 6. Date of Accident: _____________________________________________________________________ City and County of accident: ___________________________________________________________ How did the accident occur: ____________________________________________________________ Nature of the injury: __________________________________________________________________ Part(s) of the body injured: _____________________________________________________________ First date Worker was unable to perform job duties: ________________________________________ 7. Worker’s job at time of accident: ________________________________________________________ Worker’s average weekly wage: _________________________________________________________ Weekly compensation rate: ____________________________________________________________ 8. Doctor’s Name: ______________________________________________________________________ Mailing Address: _____________________________________________________________________ City/State/Zip: _______________________________________________________________________ Telephone: __________________________________________________________________________ 9. Doctor who set the maximum medical improvement: _______________________________________ Rev. 10/17 2 11.4.4.9 NMAC Date of maximum medical improvement: _________________________________________________ Impairment rating: ________ _________ Date assessed: ___________________________________ Has Worker been released to work by a Doctor? ____ Yes ____ No If yes, please indicate the date Worker was released to work: ___________________________ Has Worker returned to work since the accident? ____ Yes ____ No If yes, please indicate the date Worker returned to work: ______________________________ 10. Current Employer’s Name: _____________________________________________________________ Mailing Address: _____________________________________________________________________ City/State/Zip: _______________________________________________________________________ 11. Is an interpreter needed for the hearings on this application? ____ Yes ____ No If yes, what language? _______________________ (Employer will pay for cost of interpreter.) 12. THIS APPLICATION SEEKS THE FOLLOWING RELIEF : (check all that apply) ____ Physical Examination of Worker pursuant to Section 52-1-51 NMSA 1978 ____ Independent Medical Examination pursuant to Section 52-1-51 NMSA 1978 ____ Approval of Stipulated Reimbursement Agreement under Section 52-5-17 NMSA 1978 ____ Supplemental Compensation Order ____ Consolidation of payments into quarterly payments (not a lump sum under Section 52-5-12 NMSA 1978) ____ Determination of: ____ Bad Faith/Unfair Claims Processing ____ Fraud or ____ Retaliation ____ Attorney Fees, Amount: $ __________________ ____ Limited Discovery/Approval of Communication with HCP ____ Court Ordered Release of Medical Records ____ Other: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Rev. 10/17 3 11.4.4.9 NMAC 13. Why is this application being fled? (Be specifc, use additional pages, if necessary.) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ _________________________________________ _________________________________________ Filing Party signature Date Attorney's signature Date _________________________________________ _________________________________________ Print name Print name _________________________________________ Filing party /attorney's address _________________________________________ Filing party /attorney's city, state, zip _________________________________________ Filing party /attorney's telephone _________________________________________ Filing party / attorney’s e-mail address for service INSTRUCTIONS : Request for Setting and a Summons for each responding party shall be fled with the application, if a summons has not been previously issued. If the Worker is fling this application, the Worker shall also attach Worker’s Authorization for Use and Disclosure of Health Records. Rev. 10/17 4 11.4.4.9 NMAC Parties with questions may call the Ombudsman Hotline at 505-841-6894 or 1-866-967- 5667. Rev. 10/17 5 11.4.4.9 NMAC