STATE OF NEW MEXICO WORKERS222 COMPENSATION ADMINISTRATION , WCA No.: Worker, v. , and , Employer/Insurer. WORKER'S RESPONSE Worker responds to Employer/Insurer's Complaint and/or Application to Judge (check all that apply): I was hurt on the job. I am disabled. I have not returned to work. My doctor has not released me to return to work. Employer has not provided work within my restrictions. I gave notice of the accident to my employer within 15 days of the accident. Employer has not provided adequate medical care. The statute of limitations does not bar my entitlement to weekly benefits. A causal link between my disability and accident has been shown to a reasonable degree of medical probability. Other: Signature Date Print name Address City/State/Zip Telephone E-mail address for serviceRev. American LegalNet, Inc. www.FormsWorkFlow.com