1 11.4.4.9 NMAC STATE OF NEW MEXICO WORKERS222 COMPENSATION ADMINISTRATION , WCA No.: Worker, v. , and , Employer/Insurer. PETITION FOR LUMP SUM PAYMENT GENERAL INFORMATION: This petition seeks approval of the following lump sum payment: Lump sum payment after return to work for 6 months, earning at least 80% of the pre-injury wagepursuant to Section 52-5-12(B). Copies of wage statements should be attached. Partial lump sum payment to pay debts accumulated during the course of the disability pursuantto Section 52-5-12(C). Copies of records documenting the debts accumulated should be attached. Lump sum settlement payment pursuant to Section 52-5-12(D). Must be filed jointly by theWorker and Employer/Insurer.FACTUAL INFORMATION:Type of injury: Accidental Work Injury Occupational DiseaseWorker222s Full Name: Mailing Address:City/State/Zip: Telephone: mail Address for service: Worker222s highest level of school completed: Worker222s date of birth: Age: Sex: M FWorker222s Social Security No.: Full Name of Employer: Employer222s Address: City/State/Zip: Telephone: mail Address for service: American LegalNet, Inc. www.FormsWorkFlow.com 2 Insurance Carrier: Address: City/State/Zip: Telephone: mail Address for service: Date of Accident: City and County of accident: How did the accident occur: Nature of the injury: Part(s) of the body injured: First date Worker was unable to perform job duties: Worker222s job at time of accident: Worker222s average weekly wage: Weekly compensation rate: Doctor222s Name: Mailing Address: City/State/Zip: Telephone: Doctor who set the maximum medical improvement: Date of maximum medical improvement: Impairment rating: Date assessed: Has Worker been released to work by a Doctor? Yes NoIf yes, please indicate the date Worker was released to work: Has Worker returned to work since the accident? Yes No If yes, please indicate the date Worker returned to work: 9.Current Employer222s Name: Mailing Address: City/State/Zip: 10. Is an interpreter needed for the hearings on this application? Yes No If yes, what language? (Employer will pay for cost of interpreter.) American LegalNet, Inc. www.FormsWorkFlow.com 3 11. Medicare Eligibility:Is Worker a current Medicare beneficiary? Yes NoHas Worker applied for Social Security Disability benefits in the past 5 years? Yes NoHas Worker been diagnosed with End Stage Renal Disease? Yes No (See 42 U.S.C. 247 426-1) C.REQUEST FOR RELIEF: Please state the terms of the lump sum payment sought or agreed upon, including (1) the amount ofthe lump sum payment requested, (2) the effect the payment will have on indemnity or medical benefits, including a description of any benefits remaining if the petition is granted, (3) whether any part of the claim will be closed, (4) the amount of costs and attorneys222 fees requested, if any, and (5) the net amount to be paid to the Worker. American LegalNet, Inc. www.FormsWorkFlow.com 4 VERIFICATION OF THE WORKER I, , Worker, verify I have read this petition for lump sum payment. In accordance with NMRA 1-011(B), I swear and affirm under penalty of perjury under the laws of the State of New Mexico that representations I make in this petition are true and correct, and that I understand the terms and conditions of the proposed lump sum payment. I understand that approval of this petition will affect my future entitlement to workers222 compensation benefits. Worker222s signature Date Signature of worker222s attorney (if any) Name Address City, State, Zip Telephone E-mail address for service APPROVAL OF THE EMPLOYER/INSURER (Only required for petitions seeking lump sum settlement payments under Section 52-5-12(D)) I, , a representative of Employer/Insurer, state that I have read this petition for lump sum settlement payment, that I sign this Petition with full authority to do so. I also confirm that I understand the terms and conditions of the lump sum settlement payment and I understand that approval of this petition will affect my company222s/client222s obligation to pay under this lump sum settlement payment, and its future obligation to pay workers222 compensation benefits. Signature Date Name Address City, State, Zip Telephone E-mail address for service American LegalNet, Inc. www.FormsWorkFlow.com 5 INSTRUCTIONS FOR USE: A request for setting and a summons for each responding party shall be filed with the petition if it is an initial pleading, unless the petition is a joint petition seeking a lump sum settlement payment. American LegalNet, Inc. www.FormsWorkFlow.com