STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION
___________________________________________, Worker, v. ____________________________________________, and. ____________________________________________, Employer/Insurer.
WCA No.___________
NOTICE OF DISQUALIFICATION The ____ Worker_____ Employer,_________________________________________________________________ (Name of filing party) gives notice that Judge________________________________________________________ is disqualified from adjudicating this cause.
____________________________________ Name ____________________________________ Address ____________________________________ City/State/Zip (___)______________ (___)____________ Telephone & Fax Number
I certify a copy of this Notice of Disqualification was mailed to all parties this date___________________________. ________________________________________ (Signature of party mailing notice.)
11.4.4.9.18.2.G NMAC