Workers Response To Complaint
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Workers Response To Complaint Form. This is a New Mexico form and can be use in Workers Compensation.
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Tags: Workers Response To Complaint, New Mexico Workers Compensation,
STATE OF NEW MEXICO
WORKERS' COMPENSATION ADMINISTRATION
___________________________________________,
Worker,
v.
____________________________________________, and
WCA No.:___________________
____________________________________________,
Employer/Insurer.
WORKER'S RESPONSE TO COMPLAINT
Worker, _________________________________________________, responds to Employer/Insurer's Complaint as
indicated (check all that apply):
1.
_____
I was hurt on the job.
2.
_____
I am disabled.
3.
_____
I have not returned to work.
4.
_____
My doctor has not released me to return to work
5.
_____
Employer has not provided work within my restrictions.
6.
_____
I gave notice of the accident to my employer within 15 days of the accident.
7.
_____
Employer has not provided adequate medical care.
8.
_____
The statute of limitations does not bar my entitlement to weekly benefits.
9.
_____
A causal link between my disability and accident has been shown to a reasonable degree
of medical probability.
10.
_____
(Other): ______________________________________________________________
______________________________________________________________
______________________________________________________________
I certify a copy has been [ ] mailed [ ] faxed
to opposing party on (date): _____/ _____/ _____
______________________________________
(Signature of party mailing response)
_________________________________________
Signature
________________________________________
Print Name
________________________________________
Address
________________________________________
City/State/Zip
(____)______________ (____)______________
Telephone & Fax Number
11.4.4.9.18.2.E NMAC
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