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New Mexico Workers' Compensation Forms

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STATE OF NEW MEXICO

WORKERS' COMPENSATION ADMINISTRATION

EXECUTIVE EMPLOYEE AFFIRMATIVE ELECTION FORM

I, (Please print name), am a “worker” as defined in the New Mexico Workers' Compensation Act and the New Mexico Occupational Disease Disablement Law (“the Acts”). I am employed by (Name of corporation or limited liability company), a company subject to the provisions of the Acts. Pursuant to NMSA 1978, §52-1-7 or §52-3-6, I affirmatively elect NOT TO ACCEPT the provisions of the Acts. I meet the qualifications set forth in §52-1-7 or §52-3-6 as follows:

  • I am the chairperson of the board, president, vice president, secretary, treasurer, or other executive officer of the employer corporation or limited liability company; and
  • I own ten percent or more of the outstanding stock of the employer corporation or have at least a ten percent ownership interest in the employer limited liability company

If my business is licensed with the Construction Industries Division or is engaged in business activities that fall under the Construction Industries Licensing Act I understand that all employees, including those hired on a temporary basis, are required to be covered by workers' compensation insurance unless they are an executive employee and have filed an affirmative election form to not accept the provisions of the Act.

I understand that I may face significant monetary penalties, up to $1,000 for each occurrence, and that my business may be shut down, if my business fails to secure workers' compensation insurance when it is required. I also understand that if my business fails to obtain workers' compensation insurance when it is required to, I may be responsible for the costs associated with any claim for workers' compensation benefits, including the costs of medical and disability payments.

I understand that by making this affirmative election, it applies to all corporations or limited liability companies in which I have a financial interest. I understand that if I wish to revoke my election, I am required by law to file a revocation with my insurance carrier and with the Workers' Compensation (“WCA”) Director's Office, and to mail a copy of the revocation to the board of directors of employer corporation or limited liability company. I also agree to notify the WCA of any changes in my §52-1-7 or §52-3-6 status.

I further understand that by making this election not to accept the provisions of the Acts, I will not be entitled to workers' compensation benefits from the Uninsured Employers' Fund.

I swear or affirm under penalty of perjury that I have read the foregoing affirmative election in its entirety and understand the information contained therein is true and correct to the best of my knowledge.

Signature:
UI Number:
Executive Title:
FEIN Number:
Business Address:
Phone Number:

City/State/Zip:

STATE OF )

COUNTY OF ) ss.

)

SUBSCRIBED AND SWORN OR AFFIRMED to before me on the day of

20 by

Notary Public

My commission expires:

10/4/11

Please retain a copy of this form for your records.

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Overview of New Mexico Workers' Compensation Forms

New Mexico Workers' Compensation Forms are standardized documents used to report workplace injuries, request benefits, and document related medical treatment and lost time. Employers, employees, medical providers, and insurers use these forms to start claims, establish liability, and track benefits. The forms collect claimant identity, employer details, injury particulars, and medical information. Proper completion ensures timely adjudication, preserves benefit entitlements, and creates an auditable record for the New Mexico Workers' Compensation Administration and involved insurers.

Why accurate forms matter for claims and compliance

Complete and accurate workers' compensation forms reduce delays, lower the risk of benefit denials, and create a clear record for claims examination. They support correct benefit calculations and help employers meet statutory reporting duties.

Why accurate forms matter for claims and compliance

Who fills and relies on these forms

Each role must provide consistent, verifiable information to avoid processing delays and ensure legal compliance.

  • Workers and claimants notify employers and provide initial injury details for benefit eligibility and medical authorization.
  • Employers and HR departments record the incident, forward reports to insurers, and preserve documentation for audits.
  • Medical providers complete treatment sections to document care, work restrictions, and support benefit payments.

Essential fields to collect on every form

Claimant Name: Full legal name
Date of Injury: MM/DD/YYYY
Employer Details: Company name and address
Injury Description: Brief factual summary
Medical Provider: Name and facility
Wage Information: Average weekly wage

Step-by-step: filing a New Mexico workers' compensation claim

Follow these steps in order to create a complete claim file and initiate benefits promptly.

  • 01
    1. Notify: Employee notifies the employer immediately or as soon as practicable.
  • 02
    2. Medical Care: Seek appropriate medical evaluation and document treatment details.
  • 03
    3. Complete Form: Employer or claimant completes the workers' compensation form fully.
  • 04
    4. Submit: Send the form to the insurer and retain a copy for records.

Configuring an online form workflow

Set up fields and routing to match your internal review steps and insurer requirements.

Field Configuration
Automatic Routing Route completed forms to employer HR, insurer claims inbox, and designated safety officer
Authentication Require email verification and optional SMS code for claimant attribution
Template Fields Pre-fill employer, job title, and location to reduce data entry errors
Storage Retain signed PDFs in encrypted cloud storage with audit trail

Digital signing and technical compatibility

Platforms with audit trails, conditional fields, and enterprise integrations simplify routing and support regulatory recordkeeping.

  • Integrations: Salesforce, Microsoft 365, NetSuite, Google Workspace
  • File Formats: PDF, DOCX, HTML, Excel
  • Security: TLS 1.2/1.3 and AES-256 encryption

Where to submit completed forms

Choose the correct recipients and maintain copies for audit and compliance.

  • Primary Insurer: Submit to the employer's workers' compensation insurer claims department
  • Employer HR: Retain a signed copy in the employee's confidential personnel file
  • Medical Provider: Share treatment sections with the treating clinician as needed
  • State WCA: File only if required by the New Mexico Workers' Compensation Administration or upon request

Typical timelines and expectations

Timeframes vary by incident severity and insurer; use these common targets to avoid delay.

Employee Notice:

Notify employer immediately or within 24–72 hours typically

Employer Reporting:

Report to insurer as soon as practicable; many employers report within 7 business days

Medical Report:

Provider submits initial treatment note within 24–72 hours

Benefit Determination:

Insurers often acknowledge receipt within 7–14 days

Appeals Timelines:

Follow New Mexico WCA timelines for dispute filings; deadlines vary by case

Key milestones from injury to resolution

Track these stages to manage expectations and document compliance throughout the claim lifecycle.

01

Injury Occurs

Immediate medical care and incident details captured

02

Employer Notification

Employer documents the claim and initiates reporting

03

Insurer Intake

Insurer opens claim file and requests additional records

04

Adjudication & Closure

Resolution through payment, settlement, or hearing

Common mistakes to avoid when preparing forms

  • Incomplete injury descriptions that omit mechanism, date, or location cause delays in benefit eligibility determinations and medical authorization.
  • Mismatched names or payroll details prevent insurer verification and can trigger identity or benefit payment errors.
  • Missing or late medical reports hinder temporary disability calculations and may lead to contested benefit start dates.
  • Failing to preserve original signed documents or audit trails complicates appeals and regulatory audits.

Consequences of incorrect or late filings

Claim Denial: Possible benefit loss
Payment Delays: Temporary benefit interruptions
Fines: Employer penalties may apply
Increased Exposure: Higher insurance scrutiny
Appeal Costs: Legal fees and administrative costs
Recordkeeping Risks: Audit findings and sanctions

Core components of a professional claim form package

A complete submission combines administrative details, medical evidence, and clear attestations to support timely processing.

Claimant Details

Comprehensive identity and contact information to ensure accurate claimant matching and benefit delivery, including SSN or TIN when required for tax withholding and benefit records.

Employer Information

Legal employer name, policy number, mailing address, and payroll contacts that insurers use to confirm coverage and wage history quickly during intake and rate calculations.

Incident Narrative

A concise chronology describing how the injury occurred, ergonomic or environmental factors, and immediate symptoms to support causal relationships and initial compensability evaluations.

Medical Documentation

Treating provider notes, diagnostic results, work restrictions, and return-to-work recommendations establishing medical necessity and impairment for benefit calculations.

Wage Records

Recent payroll data, average weekly wage calculations, and overtime patterns used to compute temporary and permanent benefits according to statutory formulas.

Signatures and Attestations

Signed claimant and employer attestations confirming the accuracy of submitted information and consent for records release as needed for claims handling.

Typical eSignature pricing and capability snapshot

Comparison focused on common procurement criteria for eSignature platforms used to route and sign workers' compensation forms; signNow appears first for reference.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial Yes, 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes (Business Premium+) Varies by plan Varies by plan Varies by plan Varies by plan
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes (BAA available) Varies by plan Varies by plan Varies by plan Varies by plan
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently asked questions and troubleshooting

Answers to common questions about completing, submitting, and correcting workers' compensation forms in New Mexico.


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