Annual Expenditure Report for Insurance Carriers and Self Insured Employers NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION For detailed instructions, see page 2. 1.) Name, Address, and Parent Company Information: Insurance Carrier or Self-Insurer Name: Number of New Mexico Employees Covered: Insurance Carrier or Self-Insurer FEIN: (Self-Insurers are required to file this number) Mailing Address: City, State, Zip: Parent Carrier or Self-Insurer Name: Parent Carrier or Self-Insurer FEIN: TPA Name: TPA Phone Number: TPA Mailing Address: 2.) Number of Cases: Medical-Only Cases Note: A case can be counted more than once within a column. (See instructions on page 2.) Indemnity Cases a. With Benefit Payments in 2005 b. Opened in 2005 c. Closed in 2005 3) Payments on Medical-Only Cases in 2005 (Paid Losses During Period): a. Hospitalization b. Therapy c. Physician d. Medication e. Other (Round totals up to the next whole dollar) 4) Payments on Indemnity Cases in 2005 (Paid Losses During Period): (Round totals up to the next whole dollar) Please do NOT include recovery payments due to subrogation, third party recovery, or recovery from excess insurance. Paid Losses by Part of Body (Required-Report Dollars Expended) Paid Losses by Type of Benefit (Required-Report Dollars Expended) Head/Neck TPD Eyes TTD Arms PPD Hand/Wrist Trunk PTD Lump Sum (not distributed) Shoulder Death Benefits Back Funeral Legs Attorney (Employer) Knee Attorney (Worker) Ankle Foot Hospitalization Therapy Other Physician Medication Vocational Rehabilitation Other Total: Total: NOTE: Both the Columns & Totals for Paid Losses by Part of Body & Paid Losses by Type of Benefit Should be filled out, & Column Totals should be Equal Report Preparer (Required): Preparer Phone Number (Required): Preparer E-mail (Required): Preparer Signature: Date: (Not required if submitted electronically) Page 1 of 2 Title: American LegalNet, Inc. www.USCourtForms.com FORM WCA E5.1 (1-19-06) Purpose of the Annual Expenditure Report: New Mexico state law § 52-1-58(NMSA 1978 as amended) requires every workers’ compensation insurance carrier and self-insured employer to submit the Annual Expenditure Report to the New Mexico Workers’ Compensation Administration. Use this form to summarize workers’ compensation claim payments made during 2005 (1 January thru 31 December) for New Mexico workers. This report must be completed and sent to the Administration no later than March 15th, 2006. It is important that you provide all of the information requested. The following describes each item to be completed. This form can also be downloaded from our Web site at www.state.nm.us/wca/E5.doc and filed by e-mail. INSTRUCTIONS: Name and Address information: Insurance Carrier or Self-Insurer FEIN: Enter the Federal Employment Identification Number for the Carrier or Self-Insured Employer. No. of New Mexico Employees Covered: Self-Insurers must report the total number of New Mexico workers covered under workers’ compensation policies. TPA: Provide complete Third Party Administrator’s name, street address, phone number, (and e-mail, if available). Parent Carrier or Self-Insurer Name and FEIN: If the Insurance Carrier or Self-Insurer is a subsidiary, please enter the name and Federal Employment Identification Number for the parent Carrier or Self-Insurer. 2. A. Number of Cases (Medical-Only Case Column): NOTE: Do NOT include any cases with indemnity payments in these counts. a. With Benefit Payments in 2005: Enter the number of cases that have only medical payments made in behalf of claimant in 2005. b. Opened in 2005: Enter the number of medical-only cases that have a first payment date in 2005. c. Closed in 2005: Enter the number of medical-only cases that have a final payment date in 2005. B. Number of Cases (Indemnity Case Column): a.With Benefit Payments in 2005: Enter the number of cases in which indemnity benefits were paid to the claimant in addition to payments for medical treatment within the time period specified. b.Opened in 2005: Enter the number of cases that have a first payment within the period specified and are for any indemnity benefits paid in addition to payments for medical treatment. c.Closed in 2005: Enter the number of cases that have a final payment within the period specified and are for any indemnity benefits paid in addition to payments for medical treatment. 3. Payments on Medical-Only Cases in 2005 (Paid Losses During Period): Enter the total amounts for each category. Represents cases where only medical treatment costs have been paid. Cases where indemnity benefits were paid are NOT included here. a) Hospitalization: Enter the total amount paid to hospitals for the care of claimants’ injuries. b) Therapy: Enter the total amount paid for physical therapy and /or psychological treatment. c) Physician: Enter the total amount paid to claimants’ attending physicians. d) Medication: Enter the total amount paid for medications for claimants. 4. Payments on Indemnity Cases in 2005 (Paid Losses During Period): Enter the total amounts paid for benefits into each category. Represents cases where the claimant received indemnity benefits. A. Paid Losses by Part of Body Category: Enter the total amount for each body part injury. B. Paid Losses by Type of Benefit Category: For the time period and items defined below enter total dollar amounts. Do NOT include recovery payments due to subrogation, third party recovery, or recovery from excess insurance. a) b) c) d) e) f) g) h) i) j) k) l) m) n) o) TPD: Enter the total amount paid for Temporary Partial Disability. TTD: Enter the total amount paid for Temporary Total Disability. PPD: Enter the total amount paid for Permanent Partial Disability. PTD: Enter the total amount paid for Permanent Total Disability. Lump Sum (not distributed): Enter the total amount paid for Lump Sum settlement for which the type of disability is unknown. Death Benefits: Enter the total amount of deceased workers’ indemnity benefits paid to claimants’ relatives. Funeral: Enter the total amount paid for funeral expenses. Attorney (Employer): Enter the total amount paid to employers’ attorneys. Attorney (Worker): Enter the total amount paid to workers’ attorneys. Hospitalization: Enter the total amount paid to hospitals for the care of claimants’ injuries. Therapy: Enter the total amount paid for physical therapy and /or psychological treatment. Physician: Enter the total amount paid to claimants’ attending physicians. Medication: Enter the total amount paid for medications for claimants. Vocational Rehabilitation: Enter the total amount paid for vocational rehabilitation costs paid. Other: Enter the total amount paid for benefits not categorized on this form. Submission Instructions: Mail or Fax prior to March 15, 2006 to: New Mexico Workers’ Compensation Administration Attn: Deborah Dawson P.O. Box 27198 Albuquerque, NM 87125-7198 Fax Number: (505) 841-6883 Page 2 of 2 E-mail instructions: (Must submit by March 15, 2006) 1.) Download this form from our Web site at www.state.nm.us/wca/E5.doc. 2.) Fill in the downloaded form according to the instructions on page 2. 3.) Please save the completed form to your computer & make a back-up copy. 4.) E-mail the completed form as an attachment to research@state.nm.us. If you have any questions, please call in-state toll free 1-800-255-7965 and contact the Economic Research Bureau, or call (505) 841-6073, or e-mail to deborah.dawson@state.nm.us. American LegalNet, Inc. www.USCourtForms.com