State of New Mexico Workers’ Compensation Administration — Workers' Compensation Complaint (Rev. 8/22) (11.4.4.9 NMAC) Completed Form Examples and Samples
Find clear, filled-out examples of the State of New Mexico Workers’ Compensation Complaint form (Rev. 8/22, 11.4.4.9 NMAC). Our samples demonstrate how to properly complete the form for common issues like denial of benefits or medical treatment. Use these detailed guides to help you file your New Mexico WCA complaint accurately.
New Mexico Workers' Compensation Complaint Example – Denial of Medical Treatment
How this form was filled:
This is an example of a completed New Mexico Workers' Compensation Complaint form. The use case is a worker filing a formal complaint after their employer's insurance carrier denied a medically necessary surgical procedure following a workplace injury. The form details the worker, employer, insurance carrier, injury specifics, and the reason for the complaint.
Information used to fill out the document:
- Worker's Name: Maria Garcia
- Worker's Address: 123 Sagebrush St, Albuquerque, NM 87102
- Worker's Date of Birth: 06/15/1988
- Worker's SSN (last 4): 5678
- Date of Injury: October 28, 2025
- Employer's Name: Apex Construction LLC
- Employer's Address: 456 Industrial Blvd, Albuquerque, NM 87107
- Insurance Carrier: Southwest Insurers Group
- Insurance Carrier Address: 789 Financial Plaza, Santa Fe, NM 87501
- WCA Claim Number: SWC-2025-98765
- Body Part Injured: Lower back
- How Injury Occurred: Worker lifted a heavy box of materials improperly.
- Description of Complaint: The insurance carrier has denied a medically necessary lumbar fusion surgery recommended by the worker's authorized physician, Dr. Emily Chen. The worker is requesting an order from a judge to compel the insurer to approve and pay for the procedure.
- Relief Requested: Order compelling insurer to authorize and cover the cost of the recommended lumbar fusion surgery.
- Worker's Attorney: David Chen, Chen & Associates Law Firm
- Date of Filing: February 20, 2026
What this filled form sample shows:
- Identifies the Worker, Employer, and Insurance Carrier with complete contact information.
- Includes a specific Date of Injury and the official WCA Claim Number.
- Provides a clear and concise Description of the Complaint regarding the denial of a necessary medical procedure.
- States the specific Relief Requested from the Workers' Compensation Administration.
- Shows proper inclusion of attorney information representing the worker.
Form specifications and details:
| Form Name: | State of New Mexico Workers’ Compensation Administration — Workers' Compensation Complaint (Rev. 8/22) (11.4.4.9 NMAC) |
| Use Case: | Worker filing a complaint against an insurance carrier for the denial of a medically necessary surgical procedure. |
Created: January 29, 2026 06:39 AM
