STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION __________________________________________, Worker, v. ____________________________________________, and ____________________________________________, Employer/Insurer. WCA No.:______________
PETITION FOR LUMP SUM PAYMENT A. GENERAL INFORMATION 1. The lump sum being requested is by agreement and undisputed: ___Yes ___No 2. ____ Lump sum after return to work for 6 months, earning at least 80% of the pre-injury wage pursuant to §52-5-12(B) ____ Partial lump sum for payment of debts accumulated during the course of the disability pursuant to §52-5-12 (C) ____ Request to consolidate weekly payments into quarterly payments ____ Request to approve lump sum pursuant to §52-5-12 (D) (must be filed by joint petition and agreed by the parties and uncontested) 3. Type of injury: _____ Occupational Injury _____ Occupational Disease 4. Worker's Full Name: __________________________________________________________ Mailing Address: _____________________________________________________________ City/State/Zip: _______________________________________________________________ Telephone No.: (______)_______________________________________________________ 5. Worker's date of birth: __/__/__Age:____Sex:___M ____F 6. Worker's Social Security Number: ____-____-____ 7. Full Name of Employer: _______________________________________________________ Employer's Address: ___________________________________________________________ City/State/Zip: _______________________________________________________________ Telephone No.: (______)______________________________________________________ 8. Insurance Carrier: _____________________________________________________________ Address: ___________________________________________________________________ City/State/Zip: _______________________________________________________________ Telephone No.: (______)________________________________________________________ 9. Date of Accident:______________________________________________________________ a. City and County of accident:_______________________________________________ b. Worker's job at time of accident:____________________________________________ c. Average weekly wage: ___________________________________________________ d. Weekly compensation rate: ________________________________________________ e. How did the accident occur: _______________________________________________ f. Nature of the injury: _____________________________________________________ g. Part(s) of the body injured:________________________________________________ h. Name and address of treating Doctor:________________________________________ i. First date Worker was unable to perform job duties:_____________________________ j. Date of maximum medical improvement:_____________________________________ k. Impairment rating: ____________________Date assessed: ______________________ Doctor's Name:_________________________________________________________ l. Has Worker been released to work by a Doctor? ___ Yes ___ No If yes, please indicate the date Worker was released to work:_____________________ m. Has Worker returned to work since the accident? ___Yes ___ No If yes, please indicate the date Worker returned to work:_________________________ n. Name and address of current Employer: ______________________________________ ______________________________________________________________________ o. Highest level of school completed by Worker:_________________________________
B. RETURN TO WORK LUMP SUM: Section 52-5-12 (B) 10. ___ Return to work lump sum: a. The Worker returned to work on ______________, 20____, and during the last six months Worker has been earning an average weekly wage of _________. (Attach relevant wage records) b. The Worker returned to _____ the same job; _____ modified job duties; or _____ other job duties. c. Worker's income _____ is; _____ is not at least 80% of the pre-injury average weekly wage. d. Worker has been advised of his right to other types of lump sum? ___ Yes ___ No. C. ACCUMULATED DEBTS OF WORKER: Section 52-5-12(C) 11. ___Debt based partial lump sum advance: Debts have accumulated during the Workers' disability. (Attach documentation indicating the date debt incurred during period of disability, name, address and phone number of the creditor, payment amount currently due and total balance). D. UNDISPUTED TOTAL/PARTIAL LUMP SUM: Section 52-5-12(D) 12. ___Undisputed total/partial lump sum settlement. a. The proposed settlement is (___) Total (___) Partial. b. The proposed settlement is by agreement and is undisputed by the parties? ___Yes ___No c. Describe nature of the proposed settlement, why there is a need to settle the proceeding per the agreed terms, and how the settlement provides substantial justice: ______________________________________________________________________________________ ______________________________________________________________________________________ ________________________________________________________ E. REQUEST FOR RELIEF: 13. A request is made for approval of a lump-sum settlement as follows (applicable to §52-5-12 (B), (C) & (D)): a. A lump sum payment of weekly compensation benefits in the amount of: ______________. b. The lump sum payment of weekly compensation benefits is a lump sum of (___) all remaining weekly payments; or (___) a portion of remaining weekly payments. If a partial lump sum is approved, as of the ____ day of ____, 20___, the Worker will have ________ of weekly compensation benefits remaining. [# of weeks] c. Future medical benefits will remain (____) open indefinitely or for a term of years; (____) closed. If closed, Worker shall receive $______ in lieu of future medical benefits. If future medical benefits will remain open for a term of years, the term will be ____ years from date of final approval of the settlement. Copies of records shall be attached to petition/application relevant to the need for future medical care, impairment, and other issues, as may be appropriate. d. The payment request (____) does; (____) does not include a lump sum for a mental impairment. Copies of medical records should be attached to petition relevant to mental condition, need for future medical care, as appropriate. e. The parties are seeking an award or approval of attorney fees in the amount of $________, including gross receipts tax. f. Other: ___________________________________________________________________ IF THE VERIFICATION IS NOT SIGNED BY THE WORKER, THE PETITION WILL NOT BE ACCEPTED FOR FILING BY THE WCA CLERK OF THE COURT. VERIFICATION OF THE WORKER COUNTY OF ____________ ) SS. ) STATE OF NEW MEXICO ) I, _______________________, Worker, verify I have read this petition for lump-sum settlement approval and I swear and affirm that I understand the terms and conditions of the lump-sum settlement agreement. I understand approval of this agreement will affect my future entitlement to workers' compensation benefits.
_________________________________________________ Worker's signature
SUBSCRIBED AND SWORN to before me by Worker, __________________________, on this ________ day of ________________________________, 20_______.
__________________________________________________ Notary Public My commission expires: ____________________ __________________________________________________ Signature of Worker's Attorney (if any) __________________________________________________ Name __________________________________________________ Address __________________________________________________ City, State, Zip __________________________________________________ Telephone & Fax Number
APPROVAL OF THE EMPLOYER/INSURER/OTHER (UNDISPUTED PETITIONS) I, _________________________, Employer/Insurer/Attorney, state that I have read this petition for lump-sum settlement approval, that I sign this Joint Petition with full authority to do so, and I confirm that I understand the terms and conditions of the lump-sum settlement agreement. I understand approval of this agreement will affect my company's/client's obligation to pay under this settlement, and its future obligation to pay workers' compensation
__________________________________________________ Signature __________________________________________________ Name __________________________________________________ Address __________________________________________________ City, State, Zip __________________________________________________ Telephone & Fax Number