1 11.4.4.9 NMAC STATE OF NEW MEXICO WORKERS222 COMPENSATION ADMINISTRATION , WCA No.: Worker, v. , and , Employer/Insurer. APPLICATION TO WORKERS222 COMPENSATION JUDGE 1.Type of injury: Accidental Work Injury Occupational Disease 2.Worker222s Full Name: 3.Mailing Address: City/State/Zip: Telephone: E-mail Address for service: Worker222s highest level of school completed: Worker222s date of birth: Age: Sex: M FWorker222s Social Security No.: 4.Full Name of Employer: Employer222s Address: City/State/Zip: Telephone: Email Address for service: 5.Insurance Carrier: Address: City/State/Zip: Telephone: E-mail Address for service: 6.Date of Accident: City and County of accident: How did the accident occur: Nature of the injury: American LegalNet, Inc. www.FormsWorkFlow.com 2 11.4.4.9 NMAC Part(s) of the body injured: First date Worker was unable to perform job duties: 7.Worker222s job at time of accident: Worker222s average weekly wage: Weekly compensation rate: 8.Doctor222s Name: Mailing Address: City/State/Zip: Telephone: 9.Doctor who set the maximum medical improvement: Date of maximum medical improvement: Impairment rating: Date assessed: Has Worker been released to work by a Doctor? Yes NoIf yes, please indicate the date Worker was released to work: Has Worker returned to work since the accident? Yes No If yes, please indicate the date Worker returned to work: 10.Current Employer222s Name: Mailing Address: City/State/Zip: 11.Is an interpreter needed for the hearings on this application? Yes NoIf yes, what language? (Employer will pay for cost of interpreter.) 12. THIS APPLICATION SEEKS THE FOLLOWING RELIEF: (check all that apply) Physical Examination of Worker pursuant to Section 52-1-51 NMSA 1978 Independent Medical Examination pursuant to Section 52-1-51 NMSA 1978 Approval of Stipulated Reimbursement Agreement under Section 52-5-17 NMSA 1978 Supplemental Compensation Order Consolidation of payments into quarterly payments (not a lump sum under Section 52-5-12 NMSA 1978) Determination of: Bad Faith/Unfair Claims Processing Fraud or Retaliation Attorney Fees, Amount: $ Limited Discovery/Approval of Communication with HCP Court Ordered Release of Medical Records Other: American LegalNet, Inc. www.FormsWorkFlow.com 3 11.4.4.9 NMAC 13.Why is this application being filed? (Be specific, use additional pages, if necessary.) Filing Party signature Date Attorney's signature Date Print name Print name Filing party /attorney's address Filing party /attorney's city, state, zip Filing party /attorney's telephone Filing party / attorney222s e-mail address for service INSTRUCTIONS: Request for Setting and a Summons for each responding party shall be filed with the application, if a summons has not been previously issued. If the Worker is filing this application, the Worker shall also attach Worker222s Authorization for Use and Disclosure of Health Records. Parties with questions may call the Ombudsman Hotline at 505-841-6894 or 1-866-967-5667. American LegalNet, Inc. www.FormsWorkFlow.com