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Petition For Partial Lump Sum Payment For Debts Form. This is a New Mexico form and can be use in Workers Compensation.
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Tags: Petition For Partial Lump Sum Payment For Debts, New Mexico Workers Compensation,
STATE OF NEW MEXICO
WORKERS’ COMPENSATION ADMINISTRATION
__________________________________________,
Worker,
v.
____________________________________________, and
____________________________________________,
Employer/Insurer.
WCA No.:______________
PETITION FOR PARTIAL LUMP SUM PAYMENT FOR DEBTS
This form should be used for a partial lump sum advance for payment of debts accumulated during the course of the
disability pursuant to §52-5-12 (C). Attach documentation indicating the date debt was incurred, name, address and
phone number of the creditor, payment amount currently due and total balance.
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:_________________________________________________________
This form should be used for approval of a partial lump sum advance for debts as follows:
a. A lump sum advance of weekly compensation benefits in the amount of: ______________.
11.4.4 NMAC
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b.
10.
The lump sum advance of weekly compensation benefits is a portion of remaining weekly payments.
If a partial lump sum is approved, as of the ____ day of ____, 20___, the Worker will have ________
weeks of weekly compensation benefits remaining.
c. Medical benefits shall not be affected by the terms of this lump sum advance for debts.
d. The parties are seeking an award or approval of 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 partial lump sum payment for debts. 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. I hereby certify that I have incurred debts in the amount of $___________ during the period
of disability.
____________________________________
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
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
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www.FormsWorkFlow.com