STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION __________________________________________, Worker, v. ____________________________________________, and ____________________________________________, Employer/Insurer. WCA No.:______________ JOINT PETITION FOR LUMP SUM SETTLEMENT This form should be used to request a lump sum settlement pursuant to §52-5-12 (D). In order to use this form, the parties must agree to the settlement and sign this joint petition. By filing this joint petition the parties are submitting to the jurisdiction of the Workers’ Compensation Administration. This form should not be used for return to work or partial lump sum for debt. Please note: This settlement may be affected by federal Medicare regulations if benefits for future medical care are affected. 1. 2. 3. 4. 5. 6. 7. 8. 9. Type of injury: _____ Occupational Injury _____ Occupational Disease Worker’s Full Name: __________________________________________________________ Mailing Address: _____________________________________________________________ City/State/Zip: _______________________________________________________________ Telephone No.: (______)_______________________________________________________ Worker’s date of birth: __/__/__Age:____Sex:___M ____F Worker’s Social Security Number: ____-____-____ Full Name of Employer: _____________________________________________________________ Employer’s Address: _____________________________________________________________ City/State/Zip: _____________________________________________________________ Telephone No.: (___)_________________________________________________________ Insurance Carrier: _____________________________________________________________ Address: _____________________________________________________________ City/State/Zip: _____________________________________________________________ Telephone No.: (___)_________________________________________________________ Date of Accident: _____________________________________________________________________ a. City and County of accident:_____________________________________________________ b. Worker’s job at time of accident:__________________________________________________ c. Worker’s wages at time of accident: $____hour $____ bi-weekly $____month $____year d. How did the accident occur:______________________________________________________ e. Part(s) of the body injured:_______________________________________________________ f. Type of injury/diagnosis:_________________________________________________________ g. Name and address of treating Doctor(s):_____________________________________________ _____________________________________________________________________________ h. First date Worker was unable to perform job duties:____________________________________ i. Date of maximum medical improvement:____________________________________________ j. Impairment rating:_______________________ Doctor’s Name:__________________________ k. Has Worker been released to work by a Doctor?___Yes___No If yes, indicate the date Worker was released to work:_____________________________ l. Has Worker returned to work since the accident? ___Yes___No If yes, indicate the date Worker returned to work:_______________________________________ m. Name and address of current Employer:______________________________________________ n. Highest level of school completed by Worker:_________________________________________ a. Average weekly wage:____________________________________________________________ b. Weekly compensation rate:________________________________________________________ c. Disability rating, if known:_________________________________________________________ a. The proposed settlement is (___) Total (___) Partial. 11.4.4 NMAC American LegalNet, Inc. www.FormsWorkFlow.com 10. b. The proposed settlement is by agreement and is undisputed by the parties? __Yes __No Is an interpreter needed for the hearings on this petition? ___Yes ___No. If yes, what language? _______________________ Worker will not be responsible for cost. IF THE VERIFICATION IS NOT SIGNED BY THE WORKER, THE PETITION WILL NOT BE ACCEPTED FOR FILING BY THE WCA CLERK OF THE COURT. If you have questions, please call the Ombudsman Hotline at 505-841-6894 or 1-866-967-5667. VERIFICATION OF THE WORKER I, _______________________, Worker, verify I have read this petition for lump sum settlement approval. In accordance with NMRA 1-011(B), I swear and affirm under penalty of perjury under the laws of the State of New Mexico that this petition is true and correct and that I understand the terms and conditions of the lump sum settlement agreement. I understand approval of this agreement will affect my future entitlement to workers’ compensation benefits. ____________________________________ Date _________________________________________________ Worker’s signature __________________________________________________ Signature of Worker’s Attorney (if any) __________________________________________________ Name __________________________________________________ Address __________________________________________________ City, State, Zip __________________________________________________ Telephone & Fax Number __________________________________________________ E-mail address (optional) 11.4.4 NMAC American LegalNet, Inc. www.FormsWorkFlow.com APPROVAL OF THE EMPLOYER/INSURER/OTHER (UNDISPUTED PETITIONS) I, _________________________, Employer/Insurer/Attorney, state that I have read this petition for lump sum settlement approval, that I sign this Joint Petition with full authority to do so, and I confirm that I understand the terms and conditions of the lump sum settlement agreement. I understand approval of this agreement will affect my company’s/client’s obligation to pay under this settlement and its future obligation to pay workers’ compensation benefits. ______________________________ Date __________________________________________________ Signature __________________________________________________ Name __________________________________________________ Address __________________________________________________ City, State, Zip __________________________________________________ Telephone & Fax Number __________________________________________________ E-mail address (optional) A HEARING BEFORE AND APPROVAL BY A WORKERS’ COMPENSATION JUDGE IS REQUIRED BEFORE THE LUMP SUM AGREEMENT CAN BECOME EFFECTIVE. A REQUEST FOR SETTING, PROPOSED ORDER AND SELF-ADDRESSED STAMPED ENVELOPES FOR ALL PARTIES ENTITLED TO NOTICE MUST BE SUBMITTED WITH THIS PETITION OR IT WILL NOT BE ACCEPTED FOR FILING BY THE WCA CLERK OF THE COURT. 11.4.4 NMAC American LegalNet, Inc. www.FormsWorkFlow.com