Informal Response

Rev. STATE OF NEW MEXICO WORKERS222 COMPENSATION ADMINISTRATION , WCA No.: Worker, v. , and , Employer/Insurer. INFORMAL RESPONSE Employer, by and through its Attorney/Representative, responds to Worker222s complaint as indicated (check all that apply): The Worker was not hurt on the job. The Worker is not disabled. Actual or written notice of the accident was not received within days. Employer has provided adequate medical care. The Worker has not complied with the law regarding the selection of a health care provider. The statute of limitations prohibits the Worker222s complaint from weekly compensation benefits. A causal link between disability and accident has not been shown to a reasonable medical probability. The Worker sustained a scheduled injury. (Other): Signature Date Attorney/Representative Address City/State/Zip Telephone E-mail address American LegalNet, Inc. www.FormsWorkFlow.com