Free 11.4.4 NMAC - New Mexico

STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION ___________________________________________, Worker, v. ____________________________________________, and ____________________________________________, Employer/Insurer. WCA No.:___________________

WORKER'S RESPONSE TO COMPLAINT Worker, _________________________________________________, responds to Employer/Insurer's Complaint as indicated (check all that apply): 1. 2. 3. 4. 5. 6. 7. 8. 9. _____ _____ _____ _____ _____ _____ _____ _____ _____ I was hurt on the job. I am disabled. I have not returned to work. My doctor has not released me to return to work Employer has not provided work within my restrictions. I gave notice of the accident to my employer within 15 days of the accident. Employer has not provided adequate medical care. The statute of limitations does not bar my entitlement to weekly benefits. A causal link between my disability and accident has been shown to a reasonable degree of medical probability. (Other): ______________________________________________________________ ______________________________________________________________ ______________________________________________________________

10.

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I certify a copy has been [ ] mailed [ ] faxed to opposing party on (date): _____/ _____/ _____

______________________________________ (Signature of party mailing response)

_________________________________________ Signature ________________________________________ Print Name ________________________________________ Address ________________________________________ City/State/Zip (____)______________ (____)______________ Telephone & Fax Number

11.4.4.9.18.2.E NMAC