STATE OF NEW MEXICO               WORKERS' COMPENSATION ADMINISTRATION                                             ,              WCA No.:                                                              Worker,vs.                                             ,                    Employer,                                              ,                    Insurer..           APPLICATION TO WORKERS' COMPENSATION JUDGE 1.   Type of injury:              Occupational Injury                               Occupational Disease2.   Worker's Full Name:                                    3.   Worker's date of birth:            Age:          Sex:       M       F4.   Worker's Social Security No.:      5.   Full Name of Employer:                                         Employer's Address:                                             City/State/Zip:                                                   Telephone No.:      6.   Insurance Carrier:       Address:                 City/State/Zip:     Telephone No.:      7.   Date of Accident:     a.   City and County of accident:     b.   Worker's job at time of accident:     c.   Worker's wages at time of accident:  $/hour            $      /month  $        /year     d.   How did the accident occur:     e.   Nature of the injury:     f.   Part(s) of the body injured:     g.   Name and address of treating Doctor:     h.   First date Worker was unable to perform job duties:     I.   Date of maximum medical improvement:     j.   Impairment rating:          Doctor's Name:                                              k.   Has Worker been released to work by a Doctor?                  Yes        No          If yes, please indicate the date Worker was released to          work:          l.   Has Worker returned to work since the accident?                       Yes                  No             If yes, please indicate the date Worker returned to work:      m.   Name and address of current Employer:     n.   Highest level of school completed by Worker:8.   a.   This application seeks the following relief:               Physical Examination of Worker                              Independent Medical Examination               Supplemental Compensation Order               Determination of:      Bad Faith,     Fraud, or                              Retaliation              Attorney Fees, Amount:                                           Other, Specify:                                           Filing Party's Name