STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION _________________________________________, Worker, v. _________________________________________, and _________________________________________, Employer/Insurer. WCA No.:__________________
SUMMONS FOR WORKERS' COMPENSATION COMPLAINT TO: ______________________________________ ______________________________________ ______________________________________ ____________________________________ ____________________________________ ____________________________________
GREETINGS: You are directed to serve a written response to the Workers' Compensation Complaint not less than five (5) days prior to the mediation conference, and file the same, as provided by law. You are notified that, unless you serve and file a responsive pleading or motion, the filing party may apply to the Workers' Compensation Administration for the relief demanded in the Workers' Compensation Complaint. Worker or filing party's representative: Address of Worker or filing party's representative: ___________________________________________ ___________________________________________ ___________________________________________
WITNESSED AND SEALED BY THE CLERK OF THE WCA
(SEAL) By:_______________________________________________ Date:______________________________________________
(EACH ADVERSE PARTY MUST BE NAMED IN THE SUMMONS)
11.4.4.9.18.2.B NMAC
(rev. 1/07)