STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION ___________________________________________, Worker, v. ____________________________________________, and. ____________________________________________, Employer/Insurer. WCA No.:____________________ PETITION FOR LUMP SUM PAYMENT 1. 2. 3. 4. 5. 6. 7. 8. 9. PRE-1991 INJURY The lump sum being requested is by agreement: ___Yes___No POST-1991 INJURY ____ A lump sum after a return to work for six months, while earning at least 80% of the pre-injury wage. ____ A partial lump sum for payment of debts accumulated during the course of the disability. ____ Request to consolidate payment into quarterly payments. 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. Average weekly wage:____________________________________________________________ d. Weekly compensation rate:________________________________________________________ e. How did the accident occur:_______________________________________________________ f. Type of injury/diagnosis:__________________________________________________________ g. Part(s) of the body injured:_________________________________________________________ h. Name and address of treating Doctor:________________________________________________ ______________________________________________________________________________ i. First date Worker was unable to perform job duties:_____________________________________ j. Date of maximum medical improvement:_____________________________________________ k. Impairment rating: _______________________Date assessed:____________________________ Doctor’s Name:_________________________________________________________________ l. Has Worker been released to work by a Doctor? ___ Yes ___ No If yes, please indicate the date Worker was released to work:_____________________________ m. Has Worker returned to work since the accident? ___Yes ___ No If yes, please indicate the date Worker returned to work:_________________________________ n. Name and address of current Employer:______________________________________________ ______________________________________________________________________________ o. Highest level of school completed by Worker:_________________________________________ 11.4.4.9.18.2.M NMAC American LegalNet, Inc. www.FormsWorkflow.com 10. a. b. RETURN TO WORK The Worker returned to work on __________________________________________, 20____. The Worker returned to _____ the same job; _____ modified job duties; or _____ other job duties. Worker’s income _____ is; _____ is not at least 80% of the pre-injury wage. ACCUMULATED DEBTS OF WORKER Debts have accumulated during the Workers’ disability. Attach documentation indicating the date debt was incurred, name, address and phone number of the creditor, payment amount currently due and total balance. 11. _____ 12. A request is made for approval of a lump-sum settlement as follows: a. A lump sum payment of weekly compensation benefits in the amount of: __________________. b. The lump sum payment of weekly compensation benefits is a lump sum of:______ all remaining weekly payments; or ______ a portion of remaining weekly payments. If a partial lump sum is approved, as of the ____ day of ____, 20____, the Worker will have _____________of weekly compensation benefits remaining. [number of weeks] c. Future medical benefits will remain _____ open; _____ closed. If closed, the Worker is receiving $_____in lieu of future medical benefits. d. The payment requested _____ does; _____ does not include a lump sum for a mental impairment. e. The payment request _____ does; _____ does not include a lump sum for the payment of vocational rehabilitation benefits. f. The Worker is seeking an award of attorney fees in the amount of $______, including gross receipts tax. Is an interpreter needed for the hearings on this petition? ___Yes ___No. If yes, what language? _______________________. If yes, Employer must furnish. If you have questions, call 1-800-255-7965, Adjudication Bureau. 13. VERIFICATION OF THE WORKER I, ______________________________________, verify I have read this petition for lump-sum settlement (Worker’s Name) approval and verified 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. ______________________________________________________________________________________ Worker’s Signature Date ______________________________________________________________________________________ Attorney for Worker (Print) Signature Date ________________________________________________________(___)___________(___)______________ Attorney for Worker’s Address Telephone & Fax Number _________________________________________________________________________________________ Attorney/Representative for Employer (Print) Signature Date________________________________________ ________________________________________________________(___)____________(___)_____________ Attorney/Representative for Employer’s Address Telephone & Fax Number 11.4.4.9.18.2.M NMAC American LegalNet, Inc. www.FormsWorkflow.com