Fill and Sign the Notice of Benefit Payment New Mexico 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 C A R R I E R CARRIER (NAME & ADDRESS)       CLAIM ADMINISTRATOR (NAME & ADDRESS)       PHONE #       CARRIER FEIN       PHONE #       ADMIN FEIN       E M P L O Y E R EMPLOYER (NAME, ADDRESS, & PHONE #)       EMPLOYER LOCATION ADDRESS (If different from mailing address)       EMPLOYER FEIN       NAICS CODE       TYPE OF BUSINESS       E M P L O Y E E EMPLOYEE NAME (LAST FIRST MI                   DATE OF BIRTH       SOCIAL SECURITY NUMBER       DATE HIRED       ADDRESS (INCLUDE ZIP)       GENDER MARITAL STATUS OCCUPATION/JOB TITLE      MALE FEMALE UNMARRIED SINGLE/DIVORCED MARRIED AVERAGE WEEKLY WAGE      SEPARATED PHONE #       # OF CHILDREN       UNKNOWN O C C U R E N C E 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.       T OFFICIAL USE N B DATE OF INJURY/ILLNESS       IF FATAL, DATE OF DEATH       DATE OF DISABILILTY; 1 ST DAY       8 TH DAY       PRE-EXISTING DISABILITY? YES NO S DATE OF MAX. MED. INPROVEMENT       DATE CLAIM ADMIN NOTIFIED       PERCENT OF IMPAIREMENT       DATE RELEASED TO WORK       DATE RETURNED TO WORK       RESTRICTIONS? YES NO B E N E F I T P A Y M E N T S INITIAL PAYMENT (CHECK ONE) WKLY LATE TTD TPD PPD PTD DEATH AMT       CODE       CHANGE IN PAYMENT (CHECK 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       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: 1-800-255-7965 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:  Initial payments of indemnity claims;  Closing payments of indemnity claims;  Interim changes in indemnity payments when there is a change in the type of disability payment being paid; and  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:  REPORTING PURPOSE  DATE OF PAYMENT/ACTION  CURRENT CLAIM TYPE  CURRENT CLAIM STATUS  CARRIER  CARRIER FEIN  CLAIMS ADMINISTRATOR  ADMINISTRATOR FEIN  EMPLOYER  EMPLOYER FEIN  EMPLOYEE  SOCIAL SECURITY NUMBER  DATE OF INJURY/ILLNESS  PAID TO DATE ( application items)  DATE PREPARED  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:  10 days of the date of initial indemnity payment or medical-only becoming an indemnity; or  30 days of the date of change in payment or closing payment for an indemnity claim.  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