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 DATE OF PAYMENT/ACTION CURRENT CLAIM TYPE PLEASE PRINT IN BLACK INK CURRENT CLAIM STATUS P U R P O S E ? ? ? ? ? INITIAL PAYMENT CHANGE IN PAYMENT CLOSING PAYMENT REOPENED CORRECTION COURT ? MEDICAL ONLY _______________________________ COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ? INDEMNITY . ._______________________________ ....... .. : ? BECAME INDEMNITY ________________________________ ________________________________ ________________________________ ? OTHER : : : ? ? ? ? OPEN CLOSED Index No. REOPENED REOPENED/CLOSED Calendar No. CARRIER (NAME & ADDRESS) CLAIM ADMINISTRATOR (NAME & ADDRESS) C A R R I E R E M P L O Y E R Plaintiff(s) -againstPHONE # CARRIER FEIN PHONE # JUDICIAL SUBPOENA ADMIN FEIN : : EMPLOYER (NAME, ADDRESS, & PHONE #) EMPLOYER LOCATION ADDRESS (If different from mailing address) Defendant(s) : ...................................................... EMPLOYER FEIN NAICS CODE SIC CODE TYPE OF BUSINESS EMPLOYEE NAME (LAST THE PEOPLE OF THE STATE OF NEWDATE OF BIRTH YORK FIRST MI) TO GENDER SOCIAL SECURITY NUMBER DATE HIRED E M P L O Y E E ADDRESS (INCLUDE ZIP) MARITAL STATUS OCCUPATION/JOB TITLE GREETINGS: PHONE # M F MALE FEMALE U M P K UNMARRIED SINGLE/DIVORCED MARRIED SEPARATED UNKNOWN AVERAGE WEEKLY WAGE O C C U R E N C E 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 DISABILILTY; 1 DAY ST # OF CHILDREN 8 TH DAY PRE-EXISTING DISABILITY? S YES NO DATE OF MAX. MED. INPROVEMENT 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 WKLY LATE AMT $_______________ CODE ________ Weekly Amount CHANGE IN PAYMENT (CIRCLE ONE) INITIAL PAYMENT (CIRCLE ONE) TTD TPD PPD PTD DEATH Paid To Date TTD # Weeks # Days TPD PPD PTD DEATH Category Hospital WKLY AMT $_____________ Paid To Date B E N E F I T P A Y M E N T S Category TTD Court in Witness, Honorable Begin Date County, , one of the Justices of the day of , 20 Lump Sum TPD Physician (Attorney must sign above and type name below) PPD Scheduled Whole Body PTD Scheduled Medicine Attorney(s) for Med. - Other Emplr. ­ Atty. Therapy Death Unknown Compromise Voc. Rehab. Funeral DATE PREPARED PREPARER' NAME, TITLE, & PHONE # S Office and P.O. Address Worker ­ Atty. Legal - Other Telephone No.: Other Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com NM WCA FORM E6.2 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 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