Free 11.4.4 NMAC - New Mexico


File Size: 14.6 kB
Pages: 1
Date: January 29, 2007
File Format: PDF
State: New Mexico
Category: Workers Compensation
Author: Renee Blechner
Word Count: 148 Words, 1,717 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://workerscomp.state.nm.us/downloads/docs/response.pdf

Download 11.4.4 NMAC ( 14.6 kB)


Preview 11.4.4 NMAC
STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION __________________________________________, Worker, v. __________________________________________, and __________________________________________, Employer/Insurer. RESPONSE Employer, by and through Attorney/Representative____________________________________________, responds to Worker's complaint as indicated (check all that apply): 1. 2. 3. 4. 5. _____ _____ _____ _____ _____ 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 bars the Worker's complaint for 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): ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ WCA No.:___________________

6. 7.

_____ _____

8. 9.

_____ _____

I certify a copy of the Response was mailed to each opposing party this date ______________________________________ _______________________________________ (Signature of Party mailing Response.)

_________________________________________ Signature ________________________________________ Attorney/Representative _______________________________________ Address ________________________________________ City/State/Zip (____)______________ (____)______________ Telephone & Fax Number

11.4.4.9.18.2.E NMAC