en-USWorker --en-USFor emergency medical care, go to any emergency medical facility.en-USWorkers and Employers with questions about workers' compensation may contact an Ombudsman at any New Mexico en-USen-US8 a.m. to 5 p.m., except holidays.en-USTrabajadoren-USPara emergencias m351dicas vaya a cualquier clinica / hospital.en-USTrabajadores y empleadores con preguntas acerca de la compensaci363n de los trabajadores pueden comunicarse con un en-USen-US en-USen-US341n en-USabiertas desde las ocho de la maen-US361en-USana hasta las cinco de la tarde de lunes a viernes, con en-US en-USen-USSanta Fe: (505) 476-7381 en-USNew Mexico Workers' Compensation Administration en-USPO Box 27198, Albuquerque, NM 87125en-USStatewide Helpline --en-US Linea de Asistenciaen-US1-866-WORKOMP / 1-866-967-5667en-UStoll freeen-US -- llamada sin costo de larga distanciaen-UShttps://en-USworkerscomp.nm.gov en-USNOTICE OF ACCIDENT OR OCCUPATIONAL DISEASE DISABLEMENTen-USNOTIFICACI323N DE ACCIDENTE O ENFERMEDAD DE OFICIOen-USIn accordance with New Mexico law, Section 52-1-29, Section 52-3-19 and Section 52-1-49, NMSA 1978; NMAC 11.4.4.11en-USen-USI, , was involved in an on-the-job accident or was disabled en-US en-USYo, en-US(name of employeeen-US/nombre del empleado)en-US en-US en-USen-USby an occupational disease at approximately , on , 20.en-USen-US en-US(time/en-USa la(s) hora(sen-US))en-US en-USelen-US (date/en-USen-USEmployee's social security number: Where did the accident occur? en-USen-USWhat happened? en-USen-US en-US en-USen-USen-US To be completed by Employer: þ þ en-USWorker will choose health care provider. Yes No þ en-US þ en-US If Yes, Employer has right to change health care provider after 60 days. If No, Worker has the right to change health care provider after 60 days.en-US þ þ þ þ WORKER'S INITIALS en-US en-USINICIALES DEL TRABAJADOR en-US en-USSigned: Signed/Notice Received: en-USen-US (employee/en-USempleadoen-US) en-USen-US(employer or representative/en-USempleador o representante)en-USDate/Fecha: Date/en-USFechaen-US: en-US ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE en-US INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. en-USPREVIOUS NOA FORMS ARE STILL VALID FOR USE en-US en-US en-US Form NOA-1 (9/17) ----SEE BACK OF THIS FORM---- en-US ----VER AL REVERSO DE ESTA FORMA--en-USEmployer/employee: Each keep one copy.en-US en-USEmpleador/empleado: Retener una copiaen-US. en-US en-USAlbuquerque: (505) 841-6000 - 1 (800) 255-7965en-USFarmington: (505) 599-9746 - 1 (800) 568-7310 Hobbs: (575) 397-3425 - 1 (800) 934-2450 þ en-USLas Cruces: (575) 524-6246 - 1 (800) 870-6826en-USLas Vegas: (505) 454-9251 - 1 (800) 281-7889en-USRoswell: (575) 623-3997 - 1(866) 311-8587 American LegalNet, Inc. www.FormsWorkFlow.com