STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION __________________________________________, Worker, v. ____________________________________________, and ____________________________________________, Employer/Insurer. WCA No.:______________ PETITION FOR LUMP SUM PAYMENT RETURN TO WORK This form should be used for lump sums after return to work for 6 months, earning at least 80% of the pre-injury wage pursuant to §52-5-12(B). 1. 2. 3. 4. 5. 6. 7. 8. 9. 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. Worker’s wages at time of accident: $____hour $____ bi-weekly $____month $____year d. How did the accident occur:______________________________________________________ e. Part(s) of the body injured:_______________________________________________________ f. Type of injury/diagnosis:_________________________________________________________ g. Name and address of treating Doctor(s):_____________________________________________ _____________________________________________________________________________ h. First date Worker was unable to perform job duties:____________________________________ i. Date of maximum medical improvement:____________________________________________ j. Impairment rating:_______________________ Doctor’s Name:__________________________ k. Has Worker been released to work by a Doctor?___Yes___No If yes, indicate the date Worker was released to work:___________________________________ l. Has Worker returned to work since the accident? ___Yes___No If yes, indicate the date Worker returned to work:______________________________________ m. Name and address of current Employer:______________________________________________ n. Highest level of school completed by Worker:_________________________________________ a. Average weekly wage:____________________________________________________________ b. Weekly compensation rate:________________________________________________________ c. Disability rating, if known:_________________________________________________________ a. The Worker returned to work on ______________, 20____. (Relevant wage records should be attached and must be provided at hearing.) 11.4.4 NMAC American LegalNet, Inc. www.FormsWorkFlow.com b. 10. 11. The Worker returned to _____ the same job; _____ modified job duties; or _____ other job duties; or ______ other situation applies. Please explain: _____________________________________. c. Worker’s income _____ is; _____ is not at least 80% of the pre-injury average weekly wage. If not, explain: __________________________________________________________________ A request is made for approval of a lump sum payment 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. Medical benefits shall not be affected under the terms of this lump sum payment. c. Is a discount being taken? If yes, state the percentage and amount: _________________________ d. Attorney fees in the amount of $________, including gross receipts tax. e. Other: ___________________________________________________________________ Is an interpreter needed for the hearings on this petition? ___Yes ___No. If yes, what language? _______________________ Worker will not be responsible for cost. IF THE VERIFICATION IS NOT SIGNED BY THE WORKER, THE PETITION WILL NOT BE ACCEPTED FOR FILING BY THE WCA CLERK OF THE COURT. VERIFICATION OF THE WORKER I, _______________________, Worker, verify I have read this petition for lump sum payment return to work. 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 this petition is true and correct and that I understand the terms and conditions of the lump sum settlement payment. I understand approval of this petition will affect my future entitlement to workers’ compensation benefits. ____________________________________ Date _________________________________________________ Worker’s signature __________________________________________________ Signature of Worker’s Attorney (if any) __________________________________________________ Name __________________________________________________ Address __________________________________________________ City, State, Zip __________________________________________________ Telephone & Fax Number __________________________________________________ E-mail address (optional) A Summons for each adverse party shall be filed with the petition if one has not been previously filed. If you have questions, please call the Ombudsman Hotline at 505-841-6894 or 1-866-967-5667. A HEARING BEFORE AND APPROVAL BY A WORKERS’ COMPENSATION JUDGE IS REQUIRED BEFORE THE LUMP SUM AGREEMENT CAN BECOME EFFECTIVE. A REQUEST FOR SETTING, PROPOSED ORDER AND SELF-ADDRESSED STAMPED ENVELOPES FOR ALL PARTIES ENTITLED TO NOTICE MUST BE SUBMITTED WITH THIS PETITION OR IT WILL NOT BE ACCEPTED FOR FILING BY THE WCA CLERK OF THE COURT. 11.4.4 NMAC American LegalNet, Inc. www.FormsWorkFlow.com