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Fill and Sign the New Mexico Workers 497319878 Form

Fill and Sign the New Mexico Workers 497319878 Form

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Apply your legally-binding eSignature.
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STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINI STRATION _____________________________________________, WCA No.:____________________ Worker, v. _____________________________________________, and _____________________________________________, Employer/Insurer. REQUEST FOR SETTING 1. WCA Judge assigned: ____________________________________________________________ 2. Are any other hearings currently set? ____ Yes ____ No If yes, please indicate the date of the hearing: ________________________________________ 3. Specific matter to be heard: _______________________________________________________ 4. Time required for hearing: ________________________________________________________ 5. Is an interpreter required? ____ Yes ____ No (Employer/Insurer is responsible for making arrangements for the interpreter.) 6. Is telephonic appearance being requested? ____ Yes ____ No (Employer/Insurer is responsible for arranging the conference call.) __________________________________________ Signature ___________________________________________ Print name __________________________________________ Address Rev. 10/17 11.4.4.9 NMAC ___________________________________________ City/State/Zip ___________________________________________ Telephone ___________________________________________ E-mail address for service Rev. 10/17 11.4.4.9 NMAC

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