State of New Mexico Workers’ Compensation Administration — Workers' Compensation Complaint (Rev. 8/22) (11.4.4.9 NMAC) Instructions

The calendar date when the workplace accident occurred.

The city and county where the accident took place.

A brief description of how the accident happened, including actions, equipment, or conditions that led to the incident.

A concise description of the injury or injuries sustained as a result of the accident.

Enter the date the attorney signed this form.

Enter the attorney's full printed name as it should appear on the form.

Enter the filing party's or attorney's complete mailing address, including street, city, state, and ZIP code.

Check this box when the worker is seeking all benefits available to them under the New Mexico Workers’ Compensation Act for this claim.

Check this box when the worker is seeking temporary total disability benefits for a period they were completely unable to work due to the injury.

Check this box when the claim includes a request for death benefits on behalf of a deceased worker or their survivors.

Check this box when the worker is seeking permanent total disability benefits because the injury permanently prevents all gainful employment.

Check this box when the worker is seeking recovery of attorney fees associated with representation in this workers’ compensation claim.

Check this box when the worker is seeking permanent partial disability benefits for a lasting impairment that partially limits work capacity.

Check this box when the worker is seeking compensation for disfigurement resulting from the work-related injury.

Enter the worker's full legal name as it should appear on the complaint.

Enter the full legal name of the employer involved in this workers' compensation case.

Enter the full legal name of the insurer (or insurance company) associated with the employer in this case.

Check this box if the Albuquerque WCA office is the closest to you and should be contacted to provide equipment if you do not have the equipment for mediation/hearings. Fill only if 'Equipment for Online Video/Telephonic Hearings – No' is 'Yes'.

Check this box if the Farmington WCA office is the closest to you and should be contacted to provide equipment if you do not have the equipment for mediation/hearings. Fill only if 'Equipment for Online Video/Telephonic Hearings – No' is 'Yes'.

Check this box if the Hobbs WCA office is the closest to you and should be contacted to provide equipment if you do not have the equipment for mediation/hearings. Fill only if 'Equipment for Online Video/Telephonic Hearings – No' is 'Yes'.

Check this box if the Las Cruces WCA office is the closest to you and should be contacted to provide equipment if you do not have the equipment for mediation/hearings. Fill only if 'Equipment for Online Video/Telephonic Hearings – No' is 'Yes'.

Check this box if the Las Vegas WCA office is the closest to you and should be contacted to provide equipment if you do not have the equipment for mediation/hearings. Fill only if 'Equipment for Online Video/Telephonic Hearings – No' is 'Yes'.

Check this box if the Roswell WCA office is the closest to you and should be contacted to provide equipment if you do not have the equipment for mediation/hearings. Fill only if 'Equipment for Online Video/Telephonic Hearings – No' is 'Yes'.

Check this box if the Santa Fe WCA office is the closest to you and should be contacted to provide equipment if you do not have the equipment for mediation/hearings. Fill only if 'Equipment for Online Video/Telephonic Hearings – No' is 'Yes'.

Enter the full legal name of the worker's current employer or employing company at the time of this report.

Provide the employer's complete mailing address (street address or P.O. Box) where correspondence should be sent.

Enter the city, state (abbreviation) and ZIP code for the employer's mailing address.

Check this box to indicate you are requesting a formal determination regarding the claim (then select the specific basis below).

Check this box if you are requesting a determination that the insurer engaged in bad faith or unfair claims processing related to this claim.

Check this box if you are requesting a determination alleging fraud in connection with the claim.

Check this box if you are requesting a determination that the employer or insurer retaliated against the worker for filing or pursuing the claim.

Check this box when the employer is filing a complaint to request a credit or recovery for an overpayment of benefits.

Check this box when the employer is filing a complaint regarding the determination of compensability or the provision/denial of benefits.

Check this box when the employer's complaint is not listed among the options above and you will provide a specific description of the other complaint in the space provided.

Enter a brief, specific description of any other complaint the employer is raising that is not listed above; include relevant details or identifiers so the issue is clear. Fill only if 'Other (specify)' is 'Yes'.

Check this box when the employer is filing a complaint asserting a right to reimbursement (i.e., seeking repayment or reimbursement from the employee or another party).

Check this box when the employer is alleging a decrease or removal of a safety device and is identifying the specific device by name on this complaint.

Enter the name or designation of the safety device for which the employer is requesting a decrease. Fill only if 'Safety device decrease (name device)' is 'Yes'.

Check this box when the employer is alleging a complaint to suspend or reduce an employee's benefits under state grounds.

Enter a detailed explanation of the alleged state grounds for suspension or reduction of benefits, including the specific grounds, relevant facts, dates, and any actions or outcomes you are requesting. Fill only if 'Suspension or reduction of benefits (state grounds)' is 'Yes'.

Enter the employer's full mailing/street address, including suite, unit or P.O. Box if applicable.

Enter the employer's city, state (use the two-letter abbreviation) and ZIP code in a single line (e.g., Albuquerque, NM 87102).

Enter the employer's main telephone number including area code and any extension if applicable.

Enter the employer's primary contact email address for correspondence regarding this claim.

Check this box if you do have the necessary equipment to attend mediation and hearings via online video link or by telephone.

Check this box if you do not have the necessary equipment to attend mediation and hearings via online video link or by telephone.

Enter the date when the filing party signed the form.

Enter the full printed name of the filing party who signed the form.

Enter the street address (including suite or unit number if applicable) for the filing party or attorney.

Enter the city, two‑letter state abbreviation, and ZIP code for the filing party or attorney (e.g., Albuquerque, NM 87102).

Enter a contact telephone number for the filing party or attorney, including area code and any extension if needed.

Describe the body part(s) injured in the incident (for example, left wrist, lower back, or head).

Enter the first date the worker was unable to perform job duties due to the injury.

Provide the worker's job title or a brief description of their duties at the time of the accident.

Enter the worker's average weekly wage at the time of the injury. Fill only if 'Average weekly wage — To be determined/disputed' is 'No'.

Check this box when the worker's average weekly wage has not yet been established or is being disputed and therefore is to be determined.

Enter the worker's weekly workers' compensation rate if known. Fill only if 'Weekly compensation rate — To be determined/disputed' is 'No'.

Check this box when the worker's weekly compensation rate has not yet been established or is being disputed and therefore is to be determined.

Enter the insurance carrier's full street address (PO Box or physical address) including suite or unit number if applicable.

Enter the city, two-letter state abbreviation, and ZIP code for the insurance carrier (e.g., Albuquerque, NM 87101).

Enter the insurance carrier's daytime telephone number including area code and extension if available.

Enter the insurance carrier's primary contact e-mail address for correspondence about the claim.

Check this box if you need an interpreter for the hearings on this complaint.

Check this box if you do not need an interpreter for the hearings on this complaint.

Enter the language (or languages) needed for the interpreter to assist at the hearings (e.g., Spanish, American Sign Language). Fill only if 'Interpreter needed – Yes' is 'Yes'.

Full name of the doctor who determined the worker's maximum medical improvement.

Date when the worker reached maximum medical improvement as determined by the doctor. Fill only if 'Date of maximum medical improvement: Unknown/To be determined' is 'No'.

Check this box when the date of maximum medical improvement (MMI) is not known or will be determined later.

Numeric impairment rating assigned to the worker, typically expressed as a percentage.

Date on which the impairment rating was assessed by the doctor. Fill only if 'Impairment rating/Date assessed: Unknown/To be determined' is 'No'.

Check this box when the impairment rating or the date it was assessed is not known or will be determined later.

Check this box if you are seeking medical benefits and will list or attach unpaid medical bills related to the worker's claim.

Enter the unpaid medical benefits or bills related to this claim (or note that attached bills are provided), including provider name, date(s) of service, brief description of treatment, and the outstanding amount for each entry. Fill only if 'Medical benefits (list here or attach unpaid bills)' is 'Yes'.

Check this box if the worker is currently enrolled as a Medicare beneficiary.

Check this box if the worker is not currently enrolled as a Medicare beneficiary.

Check this box if the worker has applied for Social Security Disability benefits within the past five years.

Check this box if the worker has not applied for Social Security Disability benefits within the past five years.

Check this box if the worker has been medically diagnosed with end-stage renal disease (ESRD).

Check this box if the worker has not been diagnosed with end-stage renal disease (ESRD).

Check this box when the worker is claiming a mental impairment as a basis for benefits or relief.

Check this box when the worker's mental impairment is the primary diagnosis or primary condition for the claim. Fill only if 'Mental impairment (claim)' is 'Yes'.

Check this box when the worker's mental impairment is a secondary or contributing condition to another primary impairment. Fill only if 'Mental impairment (claim)' is 'Yes'.

Check this box if the worker is seeking a benefit or relief not listed above, and provide the specific benefit(s) in the adjacent text field.

Enter a clear, concise description of any other benefits or relief you are seeking that are not listed above (e.g., specific benefit type, amount requested, or reason), using additional sheets if more space is needed. Fill only if 'Other (specify)' is 'Yes'.

Enter a detailed, specific explanation of all reasons and facts that support your complaint, including dates, names, events, and any other relevant information; attach additional pages if necessary.

Check this box when the worker is seeking an increase for a safety device (enter the device name on the line provided) as part of the benefits or relief sought.

Enter the full name or description of the safety device for which an increase is being requested (for example: make/model or descriptive name such as 'power wheelchair', 'prosthetic leg', 'back brace'). Fill only if 'Safety device increase (name device)' is 'Yes'.

Enter the treating doctor's full name, including any professional credentials (for example, Jane Doe, MD).

Enter the doctor's mailing street address where correspondence should be sent (street address, suite or P.O. Box as applicable).

Enter the city, state and ZIP code for the doctor's mailing address.

Enter the doctor's primary telephone number for contact, including area code.

Enter the Workers' Compensation Administration (WCA) case or file number assigned to this claim (the identifying case number shown after 'WCA No.').

Check this box if a doctor has released the worker to return to work.

Check this box if a doctor has not released the worker to return to work.

Enter the date the treating doctor released the worker to return to any work following the injury. Fill only if 'Released back to work by Doctor — Yes' is 'Yes'.

Check this box if the worker has returned to any work (full, modified, or light duty) since the accident.

Check this box if the worker has not returned to any work since the accident.

Enter the date the worker actually returned to any work duties after the accident. Fill only if 'Returned to any work since the accident — Yes' is 'Yes'.

Enter the worker's full mailing street address or P.O. Box as it should appear for postal correspondence.

Enter the worker's city, two‑letter state abbreviation, and ZIP code on one line (e.g., Albuquerque, NM 87101).

Enter the worker's primary telephone number including area code and extension if applicable.

Enter the worker's primary email address used for contact.

Enter the worker's highest level of education completed (for example: 'No formal education', 'High school diploma', 'GED', 'Some college', 'Associate', 'Bachelor’s', or 'Graduate').

Enter the worker's date of birth.

Enter the worker's current age in years.

Check this box if the worker's sex is male.

Check this box if the worker's sex is female.

Enter the worker's Social Security Number as issued on their SSN card.