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.
Tags: Workers Response To Complaint, New Mexico Workers Compensation,
STATE OF NEW MEXICO
WORKERS' COMPENSATION ADMINISTRATION
WORKER'S RESPONSE TO COMPLAINT
Worker, _________________________________________________, responds to Employer/Insurer's Complaint as
indicated (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.
I certify a copy has been [ ] mailed [ ] faxed
to opposing party on (date): _____/ _____/ _____
(Signature of party mailing response)
Telephone & Fax Number
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