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Fill and Sign the New Mexico Workers 497319890 Form

Fill and Sign the New Mexico Workers 497319890 Form

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Open the document and fill out all its fields.
Apply your legally-binding eSignature.
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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 accident. ____ Employer has not provided adequate medical care. ____ The statute of limitations does not bar my entitlement to weekly benefts. ____ A causal link between my disability and accident has been shown to a reasonable degree of medical probability. ____ Other: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ ______________________________________ Signature _____________________________________ _ Print name ______________________________________ Address _____________________________________ _ City/State/Zip _____________________________________ _ Rev. 10/17 Telephone ______________________________________ E-mail address for service Rev. 10/17

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