New Mexico > Workers Compensation
Application To Workers Compensation Judge - New Mexico
| Application To Workers Compensation Judge Form. This is a New Mexico form and can be used in Workers Compensation . |
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STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION _________________________________________________, Worker, v. _________________________________________________, and _________________________________________________, Employer/Insurer. WCA No.:_______________ APPLICATION TO WORKERS' COMPENSATION JUDGE 1. 2. Type of injury: ______ Accidental Work Injury _______Occupational Disease Worker's Full Name: ____________________________________________________________________ Mailing Address: _______________________________________________________________________ City/State/Zip: _________________________________________________________________________ Telephone No.: ( ) ___________________________________________________________________ Worker's date of birth: / / Age: ____ Sex: ____ M ____ F ____ Worker's Social Security No.: ______-______-______ Full Name of Employer: ________________________________________________________ Employer's Address: ________________________________________________________ City/State/Zip: ________________________________________________________ Telephone No.: (____) ___________________________________________________ Insurance Carrier: ________________________________________________________ Address: ________________________________________________________ City/State/Zip: ________________________________________________________ Telephone No.: (____) ___________________________________________________ Date of Accident: ______________________________________________________________ a. City and County of accident: _______________________________________________ b. Worker's job at time of accident: ____________________________________________ c. Worker's average weekly wage: ____________________________________________ d. Weekly compensation rate: ________________________________________________ e. How did the accident occur: _______________________________________________ f. Nature of the injury: _____________________________________________________ g. Part(s) of the body injured: ________________________________________________ h. Name and address of treating Doctor(s):________________________________________ i. First date Worker was unable to perform job duties: _____________________________ j. Date of maximum medical improvement: _____________________________________ k. Impairment rating: ____________________Date assessed: ______________________ Doctor's Name: _________________________________________________________ l. Has Worker been released to work by a Doctor? ___ Yes ___ No [check one] If yes, please indicate the date Worker was released to work: _____________________ m. Has Worker returned to work since the accident? ___Yes ___ No [check one] If yes, please indicate the date Worker returned to work: _________________________ n. Name and address of current Employer: ______________________________________ ______________________________________________________________________ o. Highest level of school completed by Worker: _________________________________ a. This application seeks the following relief: _____ Physical Examination of Worker _____ Independent Medical Examination _____ Approval of Stipulated Reimbursement Agreement under Section 52-5-17 _____ Supplemental Compensation Order _____ Consolidate payments into quarterly payments (not a lump sum under Section 52-5-12) _____ Determination of: ___Bad Faith/Unfair Claims Processing ____ Fraud or _____ Retaliation 3. 4. 5. 6. 7. 8. American LegalNet, Inc. www.FormsWorkFlow.com b. _____ Attorney Fees, Amount: $__________________ Why is this application being filed? (Be specific, use additional pages, if necessary.) _______________________________________________________________________________ _______________________________________________________________________________ 9. Is an interpreter needed for the hearings on this application? ___Yes ___No. If yes, what language? _______________________ Worker will not be responsible for cost. __________________________________________________ Attorney's Signature __________________________________________________ Worker/Attorney's Name __________________________________________________ Worker/Attorney's Address __________________________________________________ Worker/Attorney's City, State, Zip __________________________________________________ Worker/Attorney's Telephone & Fax Number ________________________________________ Worker's Signature ________________________________________ Date A Summons for each adverse party shall be filed with the application if one has not been previously filed. If Worker is filing this application, an Authorization to Release Medical Information form shall be filed with the application for Physical Examination of Worker or Independent Medical Examination only. If you have questions, please call the Ombudsman Hotline at 505-841-6894 or 1-866-967-5667. American LegalNet, Inc. www.FormsWorkFlow.com
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