New Mexico > Workers Compensation
Workers Compensation Complaint - New Mexico
| Workers Compensation Complaint 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. WORKERS' COMPENSATION COMPLAINT 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 Number: _______-______-_______ 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. What benefit or relief is being sought? 1. Complaints by Worker: ___Temporary Total Disability ___Death Benefits ___Permanent Total Disability ___Attorney Fees ___Permanent Partial Disability ___Disfigurement ___Safety Device Increase (name device):____________________________________________ ___Mental Impairment: ___Primary ___Secondary WCA No.:_________________ 3. 4. 5. 6. 7. 8. American LegalNet, Inc. www.FormsWorkFlow.com 9. 10. ___Medical Benefits (list here or attach unpaid bills: ____________________________________ _____ Determination of: ____Bad Faith/Unfair Claims Processing _____Fraud or ____Retaliation ___Other (specify):_____________________________________________________________ 2. Complaints by Employer: ___Determination of Compensability/Benefits ___Safety Device Decrease (name device):___________________________________________ ___Reimbursement Right ___Credit for Overpayment ___Suspension or Reduction of Benefits (state grounds):________________________________ ____________________________________________________________________________ Other (specify):________________________________________________________________ b. State all reasons supporting this complaint (be specific; use additional pages, if necessary): ________________________________________________________________________ ____________________________________________________________________________________ Is an interpreter needed for the hearings on this complaint? ___Yes ___ No. If yes, what language? ________________________________. If yes, Employer must furnish. If you have questions, call 1-800-255-7965, Mediation Bureau. Medicare Eligibility: a. Is Worker a current Medicare beneficiary? ___ Yes ___ No b. Has Worker applied for Social Security Disability benefits in the past 5 years? ___ Yes___ No c. Has Worker been diagnosed with End Stage Renal Disease? ___ Yes ___ No (See 42 USC 426-1) __________________________________________________ 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 and insurer shall be filed with the Complaint. If the Worker is filing this Complaint, an Authorization to Release Medical Information form shall be filed with the Complaint. American LegalNet, Inc. www.FormsWorkFlow.com
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