Free E6.PDF - New Mexico

NEW MEXICO WORKERS'COMPENSATION ADMINISTRATION NOTICE OF BENEFIT PAYMENT
2410 CENTRE AVE. SE ? PO BOX 27198 ALBUQUERQUE, NM 87125-7198
OFFICIAL USE ONLY

Claims Administrator Claim No:
REPORTING PURPOSE DATE OF PAYMENT/ACTION CURRENT CLAIM TYPE

PLEASE PRINT IN BLACK INK
CURRENT CLAIM STATUS

P U R P O S E

? ? ? ? ?

INITIAL PAYMENT CHANGE IN PAYMENT CLOSING PAYMENT REOPENED CORRECTION

_______________________________ _______________________________ ________________________________ ________________________________ ________________________________

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MEDICAL ONLY INDEMNITY BECAME INDEMNITY OTHER

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OPEN CLOSED REOPENED REOPENED/CLOSED

CARRIER (NAME & ADDRESS)

CLAIM ADMINISTRATOR (NAME & ADDRESS)

C A R R I E R E M P L O Y E R

PHONE #

CARRIER FEIN

PHONE #

ADMIN FEIN

EMPLOYER (NAME, ADDRESS, & PHONE #)

EMPLOYER LOCATION ADDRESS (If different from mailing address)

EMPLOYER FEIN

NAICS CODE

SIC CODE

TYPE OF BUSINESS

EMPLOYEE NAME (LAST

FIRST

MI)

DATE OF BIRTH

SOCIAL SECURITY NUMBER

DATE HIRED

E M P L O Y E E

ADDRESS (INCLUDE ZIP)

GENDER

MARITAL STATUS

OCCUPATION/JOB TITLE

M F

MALE FEMALE

U M P K

UNMARRIED SINGLE/DIVORCED MARRIED SEPARATED UNKNOWN AVERAGE WEEKLY WAGE

PHONE #

# OF CHILDREN

DESCRIBE THE ACCIDENT. IDENTIFY HOW THE INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. INCLUDE THE NATURE OF THE INJURY AS WELL AS THE BODY PART AFFECTED.

T OFFICIAL USE

O C C U R E N C E

N B
DATE OF INJURY/ILLNESS IF FATAL, DATE OF DEATH DATE OF DISABILILTY; 1 DAY PERCENT OF IMPAIREMENT
ST

8

TH

DAY

PRE-EXISTING DISABILITY?

S
RESTRICTIONS?

YES
DATE RELEASED TO WORK

NO

DATE OF MAX. MED. INPROVEMENT

DATE CLAIM ADMIN NOTIFIED

DATE RETURNED TO WORK

INITIAL PAYMENT (CIRCLE ONE)

TTD

TPD

PPD

PTD

DEATH Paid To Date

WKLY LATE AMT $_______________ CODE ________ Weekly Amount Begin Date # Weeks

CHANGE IN PAYMENT (CIRCLE ONE)

TTD # Days

TPD

PPD

PTD

DEATH Category Hospital

YES WKLY AMT $_____________ Paid To Date

NO

B E N E F I T P A Y M E N T S

Category TTD

Lump Sum

TPD

Physician

PPD Scheduled Whole Body PTD Scheduled

Therapy

Medicine

Death Unknown Compromise Voc. Rehab. Funeral DATE PREPARED PREPARER' NAME, TITLE, & PHONE # S

Med. - Other Emplr. ­ Atty. Worker ­ Atty. Legal - Other Other

NM WCA FORM E6.2

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

INSTRUCTIONS FOR COMPLETION PURPOSE
The Notice of Benefit Payment (E6) is a follow -up report to the Employer' First Report of Injury or Illness (E1). It is filed for s all indemnity and medical only claims. It is used to report: Ø Initial payments of indemnity claims; Ø Closing payments of indemnity claims; Ø Interim changes in indemnity payments when there is a change in the type of disability payment being paid; and Ø Initial and closing payments of medical only claims. On this form, the items to be completed are dependent on the purpose of filing as well as o n information that may have previously been submitted.
ITEMS REQUIRED ON EVERY SUBMISSION

Every E6 MUST have the following blocks completed: Ø REPORTING PURPOSE Ø DATE OF PAYMENT/ACTION Ø CURRENT CLAIM TYPE Ø CURRENT CLAIM STATUS Ø CARRIER Ø CARRIER FEIN Ø CLAIMS ADMIN ISTRATOR Ø ADMINISTRATOR FEIN Ø EMPLOYER Ø EMPLOYER FEIN Ø EMPLOYEE Ø SOCIAL SECURITY NUMBER Ø DATE OF INJURY/ILLNESS Ø PAID TO DATE ( application items) Ø DATE PREPARED Ø PREPARER'S NAME, TITLE & PHONE # The required items are boldface on the front of the form.
ADDITIONAL BLOCKS TO BE COMPLETED

Other items will vary depending on reporting purpose and on information previously submitted. Instructions on which data items apply under various circumstances are provided in the Workers'Compensation Administration publication Guide to Completing and filing the Notice of Benefit Payment. Definitions of data items are also included in the Guide. QUESTIONS and requests for the Guide can be addressed to the Statistics section of the Albuquerque office at (505) 841-6072 between 8 a.m. and 5 p.m. Monday -Friday. Alternatively, call the toll -free number (1-800-255-7965) and ask for Statistics. NOTE: Please print in black ink or type, and ensure that all entries are legible before submission. An illegible or incomplete E6 may be returned to the sender.
FILING INSTRUCTIONS

WHEN TO FILE: This form MUST be filed within: Ø 10 days of the date of initial indemnity payment or medical -only becoming an indemnity; or Ø 30 days of the date of change in payment or closing payment for an indemnit y claim. Ø 180 days of the initial payment for a medical -only claim. WHERE TO FILE: Send form to: New Mexico Workers' Compensation Administration P.O. Box 27198 Albuquerque, NM 87125-7198 Attn: Statistics PENALTIES: Each instance of failure to file this form when required is punishable by a fine of up to $1,000.00