COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. Calendar No. NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION INSURER/ADMINISTRATOR PROFILE REPORT 2410 CENTRE AVE. SE ? PO BOX 27198 ALBUQUERQUE, NM 87125-7198 : : : : Plaintiff(s) JUDICIAL SUBPOENA OFFICIAL USE ONLY -against- PLEASE PRINT IN BLACK INK OR TYPE REPORTING TYPE INSURER POC INSURER CLAIMS ADMINISTRATOR SENDER/VENDOR REPORTING PURPOSE INITIAL CHANGE DELETE REPLACE DATE OF REPORT : WCA ID NUMBER Defendant(s) CHECK IF APPOPRIATE INSURED FEDERAL ID NUMBER NAME OF INSURER : ...................................................... SELF-INSURANCE CONTACT PERSON PHONE NUMBER THE PEOPLE OF THE STATE OF NEW YORK ADDRESS TO CITY MAILING ADDRESS (IF DIFFERENT) STATE ZIP PHONE EMAIL GREETINGS: CITY SENDER/VENDOR STATE ZIP PHONE EMAIL SENDER/VENDOR FEDERAL ID NUMBER WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court CONTACT of PHONE NUMBER located at County PERSON in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the ADDRESS CITY STATE ZIP PHONE E-MAIL Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena wasPAGE TRANSMISSIONmaximum penalty of ILLNESS allPOC - WEB sustained as a issued for a OF FIRST REPORT OF INJURY OR $50 and damages EDI CLAIMS FIRST REPORT OF INJURY OR ILLNESS WEB resultEDI CLAIMS NOTICE OF BENEFIT PAYMENT of your failure to comply. WEB PAGE TRANSMISSION OF NOTICE OF BENEFIT PAYMENT POC - EDI CLAIM ADMINISTRATOR CLAIM ADMIN. FEDERAL ID NUMBER Witness, Honorable Court in County, CONTACT PERSON ADDRESS , one of the Justices of the day of , 20 PHONE NUMBER (Attorney must sign above and type name below) CITY STATE ZIP PHONE E-MAIL Attorney(s) for Form WCA E8.1 (7/00) Purpose of Report: The Insurer/Administrator Profile Report is used for maintaining information on insurance carriers, self-insured employers, and claims administrators that pay workers'compensation claims or provide financial coverage of workers'compensation liability to employers in the state. This information is used to send out important rule changes or other correspondence to necessary parties. Filing Instructions: Office and P.O. Address Ø For carriers or self-insured groups providing workers'compensation coverage to employers, the insurer will complete the reporting type as insurer POC (Proof Of Coverage), complete the Reporting Purpose, Date Of Report, WCA ID Number if known, and complete the block of information for the insurer that identifies the Sender/Vendor for EDI POC. This report should be updated with changes within 30 days of those changes. Ø For carriers, self-insureds, and claims administrators providing claims administration and data reporting to the WCA, the form must be Telephone No.: completed based on the boxes checked in the reporting type block. Note: if you are sending claims data via EDI, the sender must also Facsimile No.: complete the trading partner profile form. All changes or initial reports must be submitted within 30 days of the action. Ø The WCA ID NUMBER and other information concerning submission of this form may be obtained from the Economic Research Bureau, E-Mail Address: please call (505) 841-6072. Ø If you the carrier, claims administrator or self-insured group have a vendor sendingMobile Tel. No.: administrator, the sender is POC or claims data to the required to complete this form in your behalf. American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Definitions: Index No. Calendar No. Reporting Type: This indicates who is submitting the report to the WCA. If the sender of the carrier or self-insured group is reporting POC data, then the boxes indicating Insurer POC and Sender/Vendor would be checked. If the sender is reporting claims data to the WCA, the sender would indicate both the Insurer Claims and Sender/Vendor boxes. Note: it is possible that the sender is both the claims administrator and the sender. In this case all three boxes : Plaintiff(s) would be indicated (Insurer Claims, Administrator and Sender/Vendor). : JUDICIAL SUBPOENA -against: Reporting Purpose: The reporting purpose indicates the reason the report is being sent to the WCA. Date of Report: The date of the reporting action. : INSURER BLOCK: For both the Insurer POC and Insurer Claims Reporting Type, the Name, Federal Identification Number (FEIN), Contact Person, Phone Number, Location and Mailing Address must be completed. E-mails are optional, but would assist us in providing up-to-date information in the : future. Defendant(s) SENDER/VENDOR BLOCK: All of the Name, Federal Identification Number, and Mailing Address information is required. If the sender is sending : . . then . . . . . . . . . . . . . . . information is . . . . . . . EDI, . . . an. e-mail.address with contact . . . . . . . . .also required.. . . . . . . . . . . . . . . . CLAIMS ADMINISTRATOR BLOCK: If a Claims Administrator handling claims is different than the Insurer, then the Name, Federal Identification Number, Contact Person and Mailing Address must be completed. An E-mail address is also required for EDI. THE PEOPLE Mailing Address: OF THE STATE OF NEW YORK New Mexico Workers'Compensation Administration TO Statistical Reporting Section P.O. Box 27198 Albuquerque, NM 87125-7198 GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtFor