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Fill and Sign the New Mexico Workers 497319886 Form

Fill and Sign the New Mexico Workers 497319886 Form

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STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION _____________________________________________, WCA No.:____________________ Worker, v. _____________________________________________, and _____________________________________________, Employer/Insurer. SUMMONS FOR WORKERS’ COMPENSATION COMPLAINT TO: _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ GREETINGS: You are directed to serve a written response to the Workers’ Compensation Complaint not less than fve (5) days prior to the mediation conference , and file the same, as provided by law. You are notified that, unless you serve and file a responsive pleading, the filing party may apply to the Workers’ Compensation Administration for the relief demanded in the Workers’ Compensation Complaint. Worker or filing party's representative: ____________________________________________ Address of Worker or filing party's representative: ____________________________________________ ____________________________________________ Rev. 1/18 11.4.4.9 NMAC WITNESSED AND SEALED BY THE CLERK OF THE WCA Rev. 1/18 11.4.4.9 NMAC

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