Notice Of Benefit Payment (Subsequent Report) Form. This is a New Mexico form and can be use in Workers Compensation.
Tags: Notice Of Benefit Payment (Subsequent Report), E6.2, New Mexico Workers Compensation,
NEW MEXICO WORKERS’COMPENSATION ADMINISTRATION NOTICE OF BENEFIT PAYMENT 2410 CENTRE AVE. SE ? PO BOX 27198 ALBUQUERQUE, NM 87125-7198 OFFICIAL USE ONLY Claims Administrator Claim No: REPORTING PURPOSE P U R P O S E ? ? ? ? ? PLEASE PRINT IN BLACK INK CHANGE IN PAYMENT CLOSING PAYMENT REOPENED ? ________________________________ CORRECTION OTHER O C C U R E N C E : -againstPHONE # REOPENED/CLOSED Calendar No. JUDICIAL SUBPOENA : CARRIER FEIN : PHONE # ADMIN FEIN : EMPLOYER LOCATION ADDRESS (If different from mailing address) Defendant(s) : ...................................................... EMPLOYER FEIN NAICS CODE SIC CODE TYPE OF BUSINESS THE PEOPLE OF THE STATE OF NEWDATE OF BIRTH YORK FIRST MI) SOCIAL SECURITY NUMBER DATE HIRED TO ADDRESS (INCLUDE ZIP) GENDER PHONE # MARITAL STATUS M F GREETINGS: U UNMARRIED SINGLE/DIVORCED M P K MARRIED MALE FEMALE # OF CHILDREN OCCUPATION/JOB TITLE AVERAGE WEEKLY WAGE SEPARATED UNKNOWN WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court DESCRIBE THE ACCIDENT. IDENTIFY HOW THE INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. INCLUDE THE NATURE OF THE INJURY T OFFICIAL USE AS WELL AS THE BODY PART AFFECTED. located at County of N 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 B DATE OF INJURY/ILLNESS IF FATAL, DATE OF DEATH DATE OF MAX. MED. INPROVEMENT TTD P A Y M E N T S Index No. REOPENED : Plaintiff(s) TPD PPD Category PTD DEATH Paid To Date TTD ST DATE OF DISABILILTY; 1 DAY 8 TH DAY PRE-EXISTING DISABILITY? YES S NO Your failure to comply with OF subpoena DATE RELEASED TO as a contempt of court and will make you liable to is punishable DATE CLAIM ADMIN NOTIFIED PERCENT this DATE RETURNED TO WORK RESTRICTIONS? IMPAIREMENT WORK 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. YES NO INITIAL PAYMENT (CIRCLE ONE) B E N E F I T CLOSED CLAIM ADMINISTRATOR (NAME & ADDRESS) EMPLOYEE NAME (LAST E M P L O Y E E OPEN ________________________________ EMPLOYER (NAME, ADDRESS, & PHONE #) E M P L O Y E R ? ? ? ? COURT ? MEDICAL ONLY _______________________________ COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ? INDEMNITY . ._______________________________ ....... .. : ? BECAME INDEMNITY ________________________________ INITIAL PAYMENT CARRIER (NAME & ADDRESS) C A R R I E R CURRENT CLAIM STATUS CURRENT CLAIM TYPE DATE OF PAYMENT/ACTION WKLY LATE AMT $_______________ CODE ________ Court in Witness, Honorable Begin Date County, Weekly Amount CHANGE IN PAYMENT (CIRCLE ONE) TTD TPD PPD PTD DEATH WKLY AMT $_____________ , one of the Justices of the # Weeks day of TPD # Days Lump Sum , 20 Category Paid To Date Hospital Physician (Attorney must sign above and type name below) PPD Scheduled Therapy Whole Body PTD Scheduled Medicine Attorney(s) for Death Med. - Other Unknown Emplr. – Atty. Office and P.O. Address Worker – Atty. Compromise Voc. Rehab. Legal - Other Funeral DATE PREPARED PREPARER’ NAME, TITLE, & PHONE # S Telephone No.: Other Facsimile No.: E-Mail Address: Mobile Tel. No.: NM WCA FORM E6.2 Completion of this form is not an admission that the claim is compensable under the Workers’Compensation Act. American LegalNet, Inc. www.USCourtForms.com NEW MEXICO WORKERS’COMPENSATION ADMINISTRATION Phone: (505) 841-6000 In -State Toll Free: 1-800-255-7965 INSTRUCTIONS FOR COMPLETION PURPOSE The Notice of Benefit Payment (E6) is a follow -up report to the Employer’ First Report of Injury or Illness (E1). It is filed for s COURT all indemnity and medical only claims. It is used to report: COUNTY . . Ø Initial payments .of.indemnity .claims; . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .OF. . . . . . . . Ø Closing payments of indemnity claims; : Index No. Ø Interim changes in indemnity payments when there is a change in the type of disability payment being paid; and : Calendar No. Ø Initial and closing payments of medical only claims. : JUDICIAL may have Plaintiff(s) On this form, the items to be completed are dependent on the purpose of filing as well as o n information thatSUBPOENA previously been submitted. -against: ITEMS REQUIRED ON EVERY SUBMISSION : Every E6 MUST have the following blocks completed: Ø REPORTING PURPOSE : Ø DATE OF PAYMENT/ACTION Ø CURRENT CLAIM TYPE Defendant(s) Ø CURRENT CLAIM STATUS : . Ø CARRIER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ø CARRIER FEIN Ø CLAIMS ADMIN ISTRATOR Ø ADMINISTRATOR FEIN THE Ø EMPLOYER PEOPLE OF THE STATE OF NEW YORK Ø EMPLOYER FEIN Ø EMPLOYEE TO Ø SOCIAL SECURITY NUMBER Ø DATE OF INJURY/ILLNESS Ø PAID TO DATE ( application items) Ø DATE PREPARED GREETINGS: Ø PREPARER’S NAME, TITLE & PHONE # WE COMMAND YOU, The required items are boldface on the front of the form. that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court ADDITIONAL BLOCKS TO BE COMPLETED located at County of Other items will vary depending on reporting purpose and on information previously submitted. Instructions on which data items in room , on the day of 20 , at o'clock Guide noon, and at apply under various circumstances are provided in the Workers’Compensation, Administration publication in the to Completing any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the and filing the Notice of Benefit Payment. Definitions of data items are also included in the Guide. QUESTIONS and requests for the Guide can be addressed to the Statistics section of the Albuquerque office at (505) 841-6072 between 8 a.m. and 5 p.m. Monday -Friday. Alternatively, call the toll -free number (1-800-255-7965) and ask for Statistics. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whoseand ensure that all entries issued for abefore submission. of $50 and all damages sustained as a NOTE: Please print in black ink or type, behalf this subpoena was are legible maximum penalty An illegible or incomplete E6 may be result of your failure to comply. returned to the sender. Witness, HonorableFILING INSTRUCTIONS , one of the Justices of the Court in County, day of , 20 WHEN TO FILE: This form MUST be filed within: Ø 10 days of the date of initial indemnity payment or medical -only becoming an indemnity; or Ø 30 days of the date of change in payment or closing payment for an indemnit y claim. (Attorney must sign above and type name below) Ø 180 days of the initial payment for a medical -only claim. WHERE TO FILE: Send form to: New Mexico Workers’ Compensation Administration P.O. Box 27198 Attorney(s) for Albuquerque, NM 87125-7198 Attn: Statistics PENALTIES: Each instance of failure to file this form when required is punishable by a fine of up to $1,000.00 Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com