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

STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION __________________________________________, WCA No.:___________________ W ork er, v. __________________________________________, and __________________________________________, Employer/Insurer. RESPONSE Employer, by and through Attorney/Representative____________________________________________, responds to Worker’s complaint as indi cated (check all that apply): 1. _____ The Worker was not hurt on the job. 2. _____ The Worker is not disabled. 3. _____ Actual or written notice of th e accident was not received within ___days. 4. _____ Employer has provided adequate medical care. 5. _____ The Worker has not complied with the law regarding the selection of a health care p ro v id er. 6. _____ The statute of limitations bars the Worker’s complaint for weekly compensation benefits. 7. _____ A causal link between disability and accide nt has not been shown to a reasonable medical probability. 8. _____ The Worker sustained a scheduled injury. 9. _____ (Other): ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ _________________________________________ S ig natu re ________________________________________ Attorney/Representative I certify a copy of the _______________________________________ Response was mailed to Address each opposing party _ _______________________________________ this date City/State/Zip (____)______________ (____)______________ ______________________________________ Telephone & Fax Number _______________________________________ (Signature of Party mailing Response.) 11.4.4.9.18. 2.E NMAC