Free NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION - New Mexico

NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION
EMPLOYERS' FIRST REPORT OF INJURY OR ILLNESS
2410 CENTRE AVE. SE PO BOX 27198 ALBUQUERQUE, NM 87125-7198
OFFICIAL USE ONLY PLEASE PRINT IN BLACK INK OR TYPE.
EMPLOYER ( NAME & ADDRESS INCL ZIP ) CARRIER / ADMINISTRATOR CLAIM # JURISDICTION INSURED REPORT NUMBER EMPLOYER'S LOCATION ADDRESS ( IF DIFFERENT ) PHONE NUMBER EMPLOYER FEIN POLICY PERIOD TO LOCATION # INDUSTRY CODE CLAIMS ADMINISTRATOR ( NAME, ADDRESS & PHONE NO ) OSHA LOG NUMBER REPORT PURPOSE CODE

G E N E R A L C A R R I E R
E M P L O Y E E W A G E C L A I M S A D M I N

JURISDICTION CLAIM NUMBER

CARRIER ( NAME, ADDRESS & PHONE NO )

CHECK IF APPROPRIATE SELF INSURANCE CARRIER FEIN AGENT NAME & CODE NUMBER NAME ( LAST, FIRST, MIDDLE ) ADDRESS ( INCL ZIP ) DATE OF BIRTH SOCIAL SECURITY NUMBER GENDER MALE FEMALE UNKNOWN PHONE NUMBER RATE PER: # OF DEPENDENTS MONTH OTHER: TIME OF OCCURRENC E AM PM PART OF BODY AFFECTED LAST WORK DATE # DAYS WORKED/WEEK MARITAL STATUS UNMARRIED SINGLE/DIVORCED MARRIED SEPARATED UNKNOWN NCCI CLASS CODE YES YES NO NO DATE HIRED STATE OF HIRE POLICY / SELF-INSURED NUMBER ADMINISTRATOR FEIN

OCCUPATION/JOB TITLE OR (SOC) CODE EMPLOYMENT STATUS

DAY WEEK

FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE? DATE EMPLOYER NOTIFIED

TIME EMPLOYEE BEGAN WORK O C C U R R E

AM
PM

DATE OF INJURY/ILLNESS

DATE DISABILITY BEGAN

CONTACT NAME / PHONE NUMBER

TYPE OF INJURY/ILLNESS

DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES? YES NO DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

TYPE OF INJURY / ILLNESS CODE

PART OF BODY AFFECTED CODE

ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED

HOW INJURY OR ILLNESS / ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL. N CAUSE OF INJURY CODE C E DATE RETURNED TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WERE THEY USED?
T R E A T M E N T

YES YES INITIAL TREATMENT

NO NO

PHYSICIAN / HEALTH CARE PROVIDER ( NAME & ADDRESS )

HOSPITAL ( NAME & ADDRESS )

NO MEDICAL TREATMENT MINOR: BY EMPLOYER MINOR CLINIC/HOSPITAL EMERGENCY CARE WITNESSES ( NAME & PHONE # ) HOSPITALIZED > 24 HRS FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER'S NAME & TITLE

O T H E R

NM WCA FORM E1.2

EQUIVALENT TO OSHA'S FORM 301

FORM IA-1 (7/02) © IAIABC 2002

Completion of this form is not an admission that the claim is compensable under the Workers' Compensation Act.

NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION Phone: (505) 841-6000 In-State Toll Free: 1-800-255-7965 FARMINGTON: 505-599-9746/1-800-568-7310 LAS CRUCES: 505-524-6246/1-800-870-6826 LAS VEGAS: 505-454-9251/1-800-281-7889 LOVINGTON: 505-396-3437/1-800-934-2450 Roswell: 505-623-3781 Santa Fe: 505-476-7381

FILING INSTRUCTIONS
PURPOSE: To report all alleged work-related injuries or illnesses resulting in more than 7 days of lost work or in death of the worker. This form is not an admission or denial by the employer as to whether the worker's alleged injury or illness is compensable, and must be completed by the employer or the employer's representative. WHEN TO FILE: This form must be filed within 10 days of knowledge of any alleged work-related injury or illness that results in more than 7 days of lost work. It must be filed even if the employer disputes the worker's claim of work-related injury or illness. WHERE TO FILE: Mail the original form to the New Mexico Workers' Compensation Administration (Attention: Statistics) at the address on the front of this form. Copies must also be provided to the worker and the employer's workers' compensation insurer. PENALTIES: Each instance of failure to file this form when required is punishable by a fine of up to $1,000.00.

INSTRUCTIONS FOR COMPLETION
FILLING IN THE SHADED AREAS IS OPTIONAL. The employer may wish, however, to use some of these areas (such as "Witnesses") for the employer's records. Expanded instructions are found in the publication Guide to Completing the Employer's First Report of Injury or Illness, available from the Administration's Albuquerque office (call either number bold-faced above and ask for Statistics). Please print in black ink or type, and ensure that all entries are legible before submission. An illegible or incomplete E1 may be returned. NAIC CODE: Represents the nature of the employer's business at the location where the worker was employed at the time of injury or illness exposure; derived from the federal government publication North American Industry Classification System Manual. Include this code if known. EMPLOYER'S LOCATION ADDRESS: Facility where the worker was employed at the time of injury, if different from mailing address. CARRIER: Name, mailing address and telephone number of the licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of the employer. A WCA-approved self-insured employer should enter its business name. CLAIMS ADMINISTRATOR: Name, mailing address and telephone number of the insurance carrier, agency, third party administrator or self-insured responsible for adjusting the claim. EMPLOYER, CARRIER OR ADMINISTRATOR FEIN: Federal Identification Number, assigned by the Internal Revenue Service. DID SALARY CONTINUE? Shows if the employer is continuing to pay the worker's regular wages without charge to employee benefits. DATE OF INJURY/ILLNESS: In the case of an occupational illness (arising from the worker's activity or exposure over an extended period), enter the date of diagnosis or the date first reported to the employer as possibly work-related. DATE EMPLOYER NOTIFIED: The date the worker first notified (verbally or in writing) the employer or the employer's representative of the alleged work-related injury or illness. DATE DISABILITY BEGAN: The first full day on which the worker lost time from work due to the injury or illness. TYPE OF INJURY OR ILLNESS: Briefly describe the nature of the injury (such as lacerations to the forearm) or illness (such as carpal tunnel syndrome). Be as specific as possible. PART OF BODY AFFECTED: The specific part of body affected by the injury or illness (for example, right forearm, lower back). DEPARTMENT OR LOCATION: If the accident or illness exposure did not occur on the employer's premises, enter specific address or location (for example, Client's office at 123 Main St., Yourtown, NM 87xxx). For occurrences in New Mexico, give ZIP or COUNTY. ALL EQUIPMENT, MATERIAL OR CHEMICALS: List all equipment, materials and/or chemicals the worker was using, applying, handling or operating when the injury or illness exposure occurred. Be specific (for example, decorator's scaffolding, electric sander, paintbrush and paint). Enter "NA" if not applicable. NOTE: The items listed do not have to be directly involved in the worker's injury or illness. SPECIFIC ACTIVITY: Describe the specific activity the worker was engaged in when the accident or illness exposure occurred (for example, sanding ceiling woodwork in preparation for painting). WORK PROCESS: Describe the work process the worker was engaged in when the accident or exposure occurred, such as building maintenance. Enter "NA" for not applicable if not engaged in a work process (for example, if the worker was walking along a hallway). HOW INJURY OR ILLNESS OCCURRED: Describe how the injury or illness/abnormal health condition occurred. Be very specific. Include the sequence of events and name any objects or substances that directly injured the worker or made the worker ill. (For example: worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against the hot metal.)

WORKER'S/EMPLOYER'S RIGHTS AND RESPONSIBILITIES
If you, the worker, believe that benefits are due you under the Workers' Compensation Act, and your employer or the employer's insurance carrier has failed or refused to make those benefits available to you, you have a right to file a complaint with the New Mexico Workers' Compensation Administration. Workers and employers with questions about rights or responsibilities under the Act may contact an ombudsman at any Workers' Compensation Administration regional office for information and assistance. To do so, call any of the above-listed telephone numbers (8 a.m. to 5 p.m. M-F).