STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION __________________________________________, Worker, v. __________________________________________, and __________________________________________, Employer/Insurer. RESPONSE Employer, by and through Attorney/Representative____________________________________________, responds to Worker's complaint as indicated (check all that apply): 1. 2. 3. 4. 5. _____ _____ _____ _____ _____ The Worker was not hurt on the job. The Worker is not disabled. Actual or written notice of the accident was not received within ___days. Employer has provided adequate medical care. The Worker has not complied with the law regarding the selection of a health care provider. The statute of limitations bars the Worker's complaint for weekly compensation benefits. A causal link between disability and accident has not been shown to a reasonable medical probability. The Worker sustained a scheduled injury. (Other): ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ WCA No.:___________________ 6. 7. _____ _____ 8. 9. _____ _____ I certify a copy of the Response was mailed to each opposing party this date ______________________________________ _______________________________________ (Signature of Party mailing Response.) _________________________________________ Signature ________________________________________ Attorney/Representative _______________________________________ Address ________________________________________ City/State/Zip (____)______________ (____)______________ Telephone & Fax Number 11.4.4.9.18.2.E NMAC American LegalNet, Inc. www.FormsWorkFlow.com