Rev. STATE OF NEW MEXICO WORKERS222 COMPENSATION ADMINISTRATION , WCA No. Worker, v. , and , Employer/Insurer. NOTICE OF CHANGE OF ADDRESS COMES NOW the , (Name of filing party) (Relationship to case) and hereby notifies the Workers222 Compensation Administration that my new address/ email address and telephone number are provided as follows: Signature Print name Address City/State/Zip Telephone E-mail address for service American LegalNet, Inc. www.FormsWorkFlow.com