Fill and Sign the New Mexico Workers Compensation Administration City of Form

NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION NOTICE OF BENEFIT PAYMENT 2410 CENTRE AVE. SE ? PO BOX 27198 ALBUQUERQUE, NM 87125-7198 Claims Administrator Claim No: PLEASE PRINT IN BLACK INK P U R P O S E REPORTING PURPOSE DATE OF PAYMENT/ACTION ?INITIAL PAYMENT _______________ ?CHANGE IN PAYMENT __________ ?CLOSING PAYMENT __________ ?REOPENED ___________ ?CORRECTION ____________ CURRENT CLAIM TYPE ?MEDICAL ONLY ?INDEMNITY ?BECAME INDEMNITY ?OTHER CURRENT CLAIM STATUS ?OPEN ?CLOSED ?REOPENED ?REOPENED/CLOSED CARRIER (NAME & ADDRESS) CLAIM ADMINISTRATOR (NAME & ADDRESS) C A R R I E R PHONE # CARRIER FEIN PHONE # ADMIN FEIN EMPLOYER (NAME, ADDRESS, & PHONE #) EMPLOYER LOCATION ADDRESS (If different from mailing address) E M P L O Y E R EMPLOYER FEIN NAICS CODE SIC CODE TYPE OF BUSINESS EMPLOYEE NAME (LAST FIRST MI) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED GENDER MARITAL STATUS M F U UNMARRIED SINGLE/DIVORCED OCCUPATION/JOB TITLE MALE FEMALE M MARRIED ADDRESS (INCLUDE ZIP) P SEPARATED E M P L O Y E E PHONE # # OF CHILDREN K UNKNOWN AVERAGE WEEKLY WAGE T OFFICIAL USE N DESCRIBE THE ACCIDENT. IDENTIFY HOW THE INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. INCLUDE THE NATURE OF THE INJURY AS WELL AS THE BODY PART AFFECTED. B DATE OF INJURY/ILLNESS IF FATAL, DATE OF DEATH DATE OF DISABILILTY; 1ST DAY 8TH DAY PRE-EXISTING DISABILITY? YES NO S O C C U R E N C E DATE OF MAX. MED. INPROVEMENT DATE CLAIM ADMIN NOTIFIED PERCENT OF IMPAIREMENT DATE RELEASED TO WORK DATE RETURNED TO WORK RESTRICTIONS? YES NO INITIAL PAYMENT (CIRCLE ONE) WKLY LATE TTD TPD PPD PTD DEATH AMT $_________ CODE ____ CHANGE IN PAYMENT (CIRCLE ONE) WKLY TTD TPD PPD PTD DEATH AMT $_______ Category Paid To Date Weekly Amount Begin Date # Weeks # Days Lump Sum Category Paid To Date TTD Hospital TPD Physician PPD Scheduled Whole Body Therapy PTD Scheduled Medicine Death Med. - Other Unknown Emplr. – Atty. Compromise Worker – Atty. Voc. Rehab. Legal - Other Funeral Other B E N E F I T P A Y M E N T S DATE PREPARED PREPARER’S NAME, TITLE, & PHONE # NM WCA FORM E6.2 Completion of this form is not an admission that the claim is compensable under the Workers’ Compensation Act. OFFICIAL USE ONLY NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION Phone: (505) 841-6000 In-State Toll Free: 1-80-255-7965 INSTRUCTIONS FOR COMPLETION PURPOSE The Notice of Benefit Payment (E6) is a follow-up report to the Employer’s First Report of Injury or Illness (E1). It is filed for all indemnity and medical only claims. It is used to report: Ø Initial payments of indemnity claims; Ø Closing payments of indemnity claims; Ø Interim changes in indemnity payments when there is a change in the type of disability payment being paid; and Ø Initial and closing payments of medical only claims. On this form, the items to be completed are dependent on the purpose of filing as well as on information that may have previously been submitted. ITEMS REQUIRED ON EVERY SUBMISSION Every E6 MUST have the following blocks completed: Ø REPORTING PURPOSE Ø DATE OF PAYMENT/ACTION Ø CURRENT CLAIM TYPE Ø CURRENT CLAIM STATUS Ø CARRIER Ø CARRIER FEIN Ø CLAIMS ADMINISTRATOR Ø ADMINISTRATOR FEIN Ø EMPLOYER Ø EMPLOYER FEIN Ø EMPLOYEE Ø SOCIAL SECURITY NUMBER Ø DATE OF INJURY/ILLNESS Ø PAID TO DATE (application items) Ø DATE PREPARED Ø PREPARER’S NAME, TITLE & PHONE # The required items are boldface on the front of the form. ADDITIONAL BLOCKS TO BE COMPLETED Other items will vary depending on reporting purpose and on information previously submitted. Instructions on which data items apply under various circumstances are provided in the Workers’ Compensation Administration publication Guide to Completing and filing the Notice of Benefit Payment. Definitions of data items are also included in the Guide. QUESTIONS and requests for the Guide can be addressed to the Statistics section of the Albuquerque office at (505) 841-6072 between 8 a.m. and 5 p.m. Monday-Friday. Alternatively, call the toll-free number (1-800-255-7965) and ask for Statistics. NOTE: Please print in black ink or type, and ensure that all entries are legible before submission. An illegible or incomplete E6 may be returned to the sender. FILING INSTRUCTIONS WHEN TO FILE: This form MUST be filed within: Ø 10 days of the date of initial indemnity payment or medical-only becoming an indemnity; or Ø 30 days of the date of change in payment or closing payment for an indemnity claim. Ø 180 days of the initial payment for a medical-only claim. WHERE TO FILE: Send form to: New Mexico Workers’ Compensation Administration P.O. Box 27198 Albuquerque, NM 87125-7198 Attn: Statistics PENALTIES: Each instance of failure to file this form when required is punishable by a fine of up to $1,000.00