NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION EMPLOYERS' FIRST REPORT OF INJURY OR ILLNESS 2410 CENTRE AVE. SE PO BOX 27198 ALBUQUERQUE, NM 87125-7198 OFFICIAL USE ONLY PLEASE PRINT IN BLACK INK OR TYPE. EMPLOYER ( NAME & ADDRESS INCL ZIP ) CARRIER / ADMINISTRATOR CLAIM # JURISDICTION INSURED REPORT NUMBER EMPLOYER'S LOCATION ADDRESS ( IF DIFFERENT ) PHONE NUMBER EMPLOYER FEIN POLICY PERIOD TO LOCATION # INDUSTRY CODE CLAIMS ADMINISTRATOR ( NAME, ADDRESS & PHONE NO ) OSHA LOG NUMBER REPORT PURPOSE CODE G E N E R A L C A R R I E R E M P L O Y E E W A G E C L A I M S A D M I N JURISDICTION CLAIM NUMBER CARRIER ( NAME, ADDRESS & PHONE NO ) CHECK IF APPROPRIATE SELF INSURANCE CARRIER FEIN AGENT NAME & CODE NUMBER NAME ( LAST, FIRST, MIDDLE ) ADDRESS ( INCL ZIP ) DATE OF BIRTH SOCIAL SECURITY NUMBER GENDER MALE FEMALE UNKNOWN PHONE NUMBER RATE PER: # OF DEPENDENTS MONTH OTHER: TIME OF OCCURRENC E AM PM PART OF BODY AFFECTED LAST WORK DATE # DAYS WORKED/WEEK MARITAL STATUS UNMARRIED SINGLE/DIVORCED MARRIED SEPARATED UNKNOWN NCCI CLASS CODE YES YES NO NO DATE HIRED STATE OF HIRE POLICY / SELF-INSURED NUMBER ADMINISTRATOR FEIN OCCUPATION/JOB TITLE OR (SOC) CODE EMPLOYMENT STATUS DAY WEEK FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE? DATE EMPLOYER NOTIFIED TIME EMPLOYEE BEGAN WORK O C C U R R E AM PM DATE OF INJURY/ILLNESS DATE DISABILITY BEGAN CONTACT NAME / PHONE NUMBER TYPE OF INJURY/ILLNESS DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES? YES NO DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED TYPE OF INJURY / ILLNESS CODE PART OF BODY AFFECTED CODE ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED HOW INJURY OR ILLNESS / ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL. N CAUSE OF INJURY CODE C E DATE RETURNED TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED? T R E A T M E N T YES YES INITIAL TREATMENT NO NO PHYSICIAN / HEALTH CARE PROVIDER ( NAME & ADDRESS ) HOSPITAL ( NAME & ADDRESS ) NO MEDICAL TREATMENT MINOR: BY EMPLOYER MINOR CLINIC/HOSPITAL EMERGENCY CARE WITNESSES ( NAME & PHONE # ) HOSPITALIZED > 24 HRS FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER'S NAME & TITLE O T H E R NM WCA FORM E1.2 EQUIVALENT TO OSHA'S FORM 301 FORM IA-1 (7/02) © IAIABC 2002 American LegalNet, Inc. www.FormsWorkFlow.com Completion of this form is not an admission that the claim is compensable under the Workers' Compensation Act. NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION Phone: (505) 841-6000 In-State Toll Free: 1-800-255-7965 FARMINGTON: 505-599-9746/1-800-568-7310 LAS CRUCES: 505-524-6246/1-800-870-6826 LAS VEGAS: 505-454-9251/1-800-281-7889 LOVINGTON: 505-396-3437/1-800-934-2450 Roswell: 505-623-3781 Santa Fe: 505-476-7381 FILING INSTRUCTIONS PURPOSE: To report all alleged work-related injuries or illnesses resulting in more than 7 days of lost work or in death of the worker. This form is not an admission or denial by the employer as to whether the worker's alleged injury or illness is compensable, and must be completed by the employer or the employer's representative. WHEN TO FILE: This form must be filed within 10 days of knowledge of any alleged work-related injury or illness that results in more than 7 days of lost work. It must be filed even if the employer disputes the worker's claim of work-related injury or illness. WHERE TO FILE: Mail the original form to the New Mexico Workers' Compensation Administration (Attention: Statistics) at the address on the front of this form. Copies must also be provided to the worker and the employer's workers' compensation insurer. PENALTIES: Each instance of failure to file this form when required is punishable by a fine of up to $1,000.00. INSTRUCTIONS FOR COMPLETION FILLING IN THE SHADED AREAS IS OPTIONAL. The employer may wish, however, to use some of these areas (such as "Witnesses") for the employer's records. Expanded instructions are found in the publication Guide to Completing the Employer's First Report of Injury or Illness, available from the Administration's Albuquerque office (call either number bold-faced above and ask for Statistics). Please print in black ink or type, and ensure that all entries are legible before submission. An illegible or incomplete E1 may be returned. NAIC CODE: Represents the nature of the employer's business at the location where the worker was employed at the time of injury or illness exposure; derived from the federal government publication North American Industry Classification System Manual. Include this code if known. EMPLOYER'S LOCATION ADDRESS: Facility where the worker was employed at the time of injury, if different from mailing address. CARRIER: Name, mailing address and telephone number of the licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer. A WCA-approved self-insured employer should enter its business name. CLAIMS ADMINISTRATOR: Name, mailing address and telephone number of the insurance carrier, agency, third party administrator or self-insured responsible for adjusting the claim. EMPLOYER, CARRIER OR ADMINISTRATOR FEIN: Federal Identification Number, assigned by the Internal Revenue Service. DID SALARY CONTINUE? Shows if the employer is continuing to pay the worker's regular wages without charge to employee benefits. DATE OF INJURY/ILLNESS: In the case of an occupational illness (arising from the worker's activity or exposure over an extended period), enter the date of diagnosis or the date first reported to the employer as possibly work-related. DATE EMPLOYER NOTIFIED: The date the worker first notified (verbally or in writing) the employer or the employer's representative of the alleged work-related injury or illness. DATE DISABILITY BEGAN: The first full day on which the worker lost time from work due to the injury or illness. TYPE OF INJURY OR ILLNESS: Briefly describe the nature of the injury (such as lacerations to the forearm) or illness (such as carpal tunnel syndrome). Be as specific as possible. PART OF BODY AFFECTED: The specific part of body affect