Free 11.4.4 NMAC - New Mexico

STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION ___________________________________, Worker, v. ____________________________________, and ____________________________________, Employer/Insurer. WCA No.: _________________

WORKERS' COMPENSATION COMPLAINT 1. 2. Type of injury: ___Occupational 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 wages at time of accident: $____hour $____ bi-weekly $____month $____year d. How did the accident occur:______________________________________________________ e. Part(s) of the body injured:_______________________________________________________ f. Type of injury/diagnosis:_________________________________________________________ g. Name and address of treating Doctor(s):_____________________________________________ _____________________________________________________________________________ h. First date Worker was unable to perform job duties:____________________________________ i. Date of maximum medical improvement:____________________________________________ j. Impairment rating:_______________________ Doctor's Name:__________________________ k. Has Worker been released to work by a Doctor?___Yes___No If yes, please indicate the date Worker was released to work:_____________________________ l. Has Worker returned to work since the accident? ___Yes___No If yes, please indicate the date Worker returned to work:_________________________________ m. Name and address of current Employer:______________________________________________ n. 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 ___Medical Benefits (list here or attach unpaid bills):___________________________________ ___Determination of: ____Bad Faith/Unfair Claims Processing _____Fraud or ____Retaliation ___Other (specify):_______________________________________________________________

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11.4.4.9.18.2.A NMAC

(rev. 1/07)

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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.

________________________________________ Worker's Signature ________________________________________ Date

__________________________________________________ Attorney's Signature __________________________________________________ Worker/Attorney's Name __________________________________________________ Worker/Attorney's Address __________________________________________________ Worker/Attorney's City, State, Zip __________________________________________________ Worker/Attorney's Telephone & Fax Number

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.

11.4.4.9.18.2.A NMAC

(rev. 1/07)