Fillable First Report Of Injury (Page 2 of 2) in pdf

NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION

ALBUQUERQUE

Phone: (505) 841-6000

In-State Toll Free: 1-800-255-7965

LAS CRUCES: 575-524-6246/1-800-870-6826

FARMINGTON: 505-599-9746/1-800-568-7310

LOVINGTON:

575-396-3437/1-800-934-2450

LAS VEGAS:

505-454-9251/1-800-281-7889

Santa Fe:

505-476-7381

Roswell:

575-623-3997/1-866-311-8587

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

ompleted 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

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

he 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

njury 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

known.

E MPLOYER'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

nancial 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

elf-insured responsible for adjusting the claim.

E MPLOYER, CARRIER OR ADMINISTRATOR FEIN: Federal Identification Number, assigned by the Internal Revenue Service.

D ID 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

eriod), 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

lleged work-related injury or illness.

D ATE 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

unnel syndrome). Be as specific as possible.

P ART 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

cation (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

aint). 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

xample, 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

aintenance. 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:

orker 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).

First Report Of Injury Page 2

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