Free 11.4.4 NMAC - New Mexico


File Size: 19.0 kB
Pages: 2
Date: January 29, 2007
File Format: PDF
State: New Mexico
Category: Workers Compensation
Author: Renee Blechner
Word Count: 362 Words, 4,868 Characters
Page Size: Letter (8 1/2" x 11")
URL

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

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Preview 11.4.4 NMAC
STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION _________________________________________________, Worker, v. _________________________________________________, and _________________________________________________, Employer/Insurer. WCA No.:_______________

APPLICATION TO WORKERS' COMPENSATION JUDGE 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 No.: ______-______-______ 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. Type of injury/diagnosis:_________________________________________________________ f. Part(s) of the body injured:________________________________________________________ g. Name and address of treating Doctor:_______________________________________________ ______________________________________________________________________________ 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. This application seeks the following relief: _____ Physical Examination of Worker _____ Independent Medical Examination _____ Approval of Stipulated Reimbursement Agreement under Section 52-5-17 _____ Supplemental Compensation Order _____ Determination of: _____Bad Faith/Unfair Claims Processing ____Fraud or ____Retaliation _____ Attorney Fees, Amount: $__________________

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11.4.4.9.18.2.H NMAC

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Why is this application being filed? (Be specific, use additional pages, if necessary.) _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Is an interpreter needed for the hearings on this application? ___Yes ___No. If yes, what language? _______________________ If yes, Employer must furnish. If you have questions, call 1-800-255-7965, Adjudication Bureau.

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________________________________________ 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 shall be filed with the application if one has not been previously filed. If Worker is filing this application, an Authorization to Release Medical Information form shall be filed with the application for Physical Examination of Worker or Independent Medical Examination only.

11.4.4.9.18.2.H NMAC