Get Complaint Form - New Mexico Workers Compensation Administration - Workerscomp State Nm

Filling out the Complaint Form for the New Mexico Workers Compensation Administration is essential for addressing work-related injuries or disputes. This guide provides clear steps to help users complete the form accurately and efficiently in an online environment.

Follow the steps to complete the Complaint Form with ease.

1. Use the ‘Get Form’ button to obtain the Complaint Form and open it in your preferred editor.
2. In the first section, indicate the type of injury you are filing a complaint for by selecting either 'Accidental Work Injury' or 'Occupational Disease'.
3. Provide the worker's full name, mailing address, city, state, and zip code in the designated fields.
4. Enter the telephone number, date of birth, age, and sex of the worker, ensuring to fill in the Social Security number accurately.
5. Fill in the full name and address of the employer, including city, state, and zip code, along with their telephone number.
6. Complete the insurance carrier details including their name, address, and telephone number.
7. Document the date and location of the accident, the worker's job title at the time, average weekly wage, and weekly compensation rate.
8. Explain how the accident occurred and detail the nature of the injury and any parts of the body that were injured.
9. List the name and address of the treating doctor(s) and provide information regarding the worker's inability to perform job duties.
10. Indicate if the worker has been released to work by a doctor, and provide any relevant dates regarding return to work.
11. State the highest level of education completed by the worker.
12. Articulate the benefits or relief being sought by checking the relevant complaints and providing a specific description if necessary.
13. If required, confirm if an interpreter is needed for hearings on this complaint, indicating the language if so.
14. Fill out questions regarding Medicare eligibility details accurately.
15. Sign and date the form as the worker or attorney, ensuring all contact details are provided.
16. Once you have completed the form, save your changes, then download, print, or share the form as necessary.

Complete your Complaint Form online today and ensure your rights are protected.