STATE OF NEW MEXICO WORKERS222 COMPENSATION ADMINISTRATION , WCA No.: Worker, v. , and Uninsured Employer, STATE OF NEW MEXICO UNINSURED EMPLOYERS222 FUND , Statutory Third Party. WORKERS' COMPENSATION COMPLAINT 1.Type of injury: Accidental Work Injury Occupational Disease2.Worker222s full name: Mailing address: City/State/Zip: Telephone: E-mail address: Worker222s highest level of school completed: Worker222s date of birth: Age: Sex: M FWorker222s Social Security Number: 3.Full name of Employer: Employer222s address: City/State/Zip: Telephone: E-mail address: 4.Statutory Third Party: STATE OF NEW MEXICO UNINSURED EMPLOYERS222 FUND Address: 2410 Centre Avenue SE City/State/Zip: Albuquerque, NM 87106 Telephone: 505-841-6000 E-mail address: edwarda.montoya@state.nm.us 5.Date of accident: City and county of accident: How did the accident occur: Nature of injury: Part(s) of body injured: 1 Rev. 11.4.4.9 NMAC American LegalNet, Inc. www.FormsWorkFlow.com First date Worker was unable to perform job duties: 6.Worker222s job at time of accident: Worker222s average weekly wage: Worker222s weekly compensation rate: 7.Doctor222s name: Mailing address: City/State/Zip: Telephone: 8.Doctor who set maximum medical improvement: Date of maximum medical improvement: Impairment rating: Date assessed: Has Worker been released back to work by a doctor? Yes NoIf yes, please indicate date Worker was released to work: Has Worker returned to any work since the accident? Yes No If yes, please indicate date Worker returned to work: 9.Current Employer222s name: Mailing address: City/State/Zip: 10.Is an interpreter needed for hearings on this complaint? Yes NoIf yes, what language? (Employer will pay for cost of interpreter. If you have questions, call 1-800-255-7965, WCA Mediation Bureau.) 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)12.Benefits or relief sought by Worker: Temporary total disability Death benefits Permanent total disability Attorney fees Permanent partial disability Disfigurement Safety device increase (name device): Mental impairment: Primary Secondary Medical benefits (list here or attach unpaid bills): Determination of: Bad Faith/Unfair Claims Processing Fraud or Retaliation Other (specify): 2 American LegalNet, Inc. www.FormsWorkFlow.com 13. Complaints by Employer: Determination of compensability/benefits Safety device decrease (name device): Reimbursement right Credit for overpayment Suspension or reduction of benefits (state grounds): Other (specify): 14. State all reasons supporting complaint (be specific; use additional pages, if necessary): Filing party signature Date Attorney's signature Date Print name Print name Filing party /attorney's address Filing Party /attorney's city, state, zip Filing party /attorney's telephone Filing party / attorney222s e-mail address for service INSTRUCTIONS FOR USE: A Summons for each responding party shall be filed with this Complaint. If the Worker is filing this Complaint, the Worker shall also complete and attach the Worker222s Authorization for Use and Disclosure of Health Records. Parties with questions may call the Ombudsman Hotline at 505-841-6894 or 1-866-967-5667. 3 American LegalNet, Inc. www.FormsWorkFlow.com