STATE OF NEW MEXICO               WORKERS' COMPENSATION ADMINISTRATION                                 ,                     WCA No.               Worker,vs.                                   ,               Employer,                                   ,               Insurer.                 WORKERS' COMPENSATION COMPLAINT 1.   Type of injury:                 Occupational Injury           Occupational Disease2.   Worker's Full Name:                                                                                      Mailing Address:                                                                                              City/State/Zip:                                                                                                    Telephone No.: (        )                                                                      3.   Worker's date of birth:                    Age:             Sex:     4.   Worker's Social Security Number: 5.   Full Name of Employer:        Employer's Address:      City/State/Zip:               Telephone No.: 6.   Insurance Carrier:       Insurer Carrier's 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.   Part(s) of the body injured:      f.   Type of injury:      g.   Name and address of treating Doctor(s):           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?           If yes, please indicate the date Worker was released to work:     l.   Has Worker returned to work since the accident?            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.   What benefit or relief is being sought?          1.  Complaints 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):                                                                                                                                                                           Other (specify):                                                                                              2.  Complaints by Employer:                    Determination of Compensability/Benefits                                   Safety Device Decrease (name device):                                                                Reimbursement Right               Credit for Overpayment               Suspension or Reduction of Benefits (state grounds):                                                                                                                                                                           Claim Against Subsequent Injury Fund (state basis for claim):                                  Other (specify):                                                                                        b.   State all reasons supporting this complaint (be specific; use additional pages, if          necessary): 9.   Is an interpreter needed for the hearings on this complaint?  If yes, Employer must     furnish. If you have questions, call 1-800-255-7965, Mediation Bureau.                                                                                                                                                      Worker's NameA Summons for each adverse party and insurer shall be filed with the Complaint.  If the Workeris filing this Complaint, an Authorization to Release Medical Information form shall be filed withthe Complaint.