Free 11.4.4 NMAC - New Mexico

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

NOTICE OF ACCEPTANCE OR REJECTION OF RECOMMENDED RESOLUTION FAILURE TO FILE THIS NOTICE WITHIN THIRTY (30) DAYS FROM THE DATE YOU RECEIVED THE RECOMMENDED RESOLUTION WILL RESULT IN YOUR BEING BOUND BY THE RECOMMENDED RESOLUTION. 1. (Name of the party filing this notice:) ___________________________________________________ gives notice the Recommended Resolution of the Mediator is: _______Accepted ______Rejected

YOU MUST STATE YOUR SPECIFIC REASONS FOR REJECTION OF THE RECOMMENDED RESOLUTION. 2. The Recommended Resolution is rejected because:_____________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

____________________________________ Signature ____________________________________ Name of Worker/Attorney/Representative ____________________________________ Address ____________________________________ City/State/Zip (___)____________(____)______________ Telephone & Fax Number I certify a copy of this Notice of Acceptance or Rejection of Recommended Resolution was mailed to all parties this date_________________________. ________________________________________________ (Signature of party mailing notice.)