The New Mexico Report form is a document used to report work-related injuries or illnesses that result in more than seven days of lost work or the death of a worker. This form must be completed by the employer or their representative and submitted to the New Mexico Workers' Compensation Administration within ten days of learning about the incident. It serves as an official record of the injury or illness and is crucial for processing claims under the Workers' Compensation Act.
The New Mexico Report Form, officially known as the Employer's First Report of Injury or Illness, serves as a crucial document for employers to report work-related injuries or illnesses. This form must be completed whenever an employee suffers an injury or illness that results in more than seven days of lost work or, in the unfortunate event of a fatality. It requires detailed information about the employer, the injured employee, and the specifics of the incident, including the nature of the injury, the part of the body affected, and the circumstances surrounding the event. Employers must submit this form within ten days of becoming aware of the incident, even if they dispute the claim. The form is not only a means of reporting but also a tool for ensuring compliance with the New Mexico Workers' Compensation Act. Failure to file this report on time can lead to significant penalties, underscoring the importance of timely and accurate submission. Additionally, the form includes sections for the employer's insurance carrier and claims administrator, ensuring that all relevant parties are informed and involved in the process. By understanding the requirements and implications of the New Mexico Report Form, employers can better navigate the complexities of workers' compensation claims and protect both their employees and their business interests.
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 # OSHA LOG NUMBER
REPORT PURPOSE CODE
G
E
JURISDICTION
JURISDICTION CLAIM NUMBER
N
INSURED REPORT NUMBER
R
EMPLOYER'S LOCATION ADDRESS ( IF DIFFERENT )
LOCATION #
A
PHONE NUMBER
EMPLOYER FEIN
INDUSTRY CODE
L
C
CARRIER ( NAME, ADDRESS & PHONE NO )
POLICY PERIOD
CLAIMS ADMINISTRATOR ( NAME, ADDRESS & PHONE NO )
TO
RA I
M
CHECK IF APPROPRIATE
S
SELF INSURANCE
I
D
CARRIER FEIN
POLICY / SELF-INSURED NUMBER
ADMINISTRATOR FEIN
AGENT NAME & CODE NUMBER
NAME ( LAST, FIRST, MIDDLE )
DATE OF BIRTH
SOCIAL SECURITY NUMBER
DATE HIRED
STATE OF HIRE
ADDRESS ( INCL ZIP )
GENDER
MARITAL STATUS
OCCUPATION/JOB TITLE OR (SOC)
P
MALE
UNMARRIED
CODE
SINGLE/DIVORCED
O
FEMALE
MARRIED
EMPLOYMENT STATUS
Y
UNKNOWN
SEPARATED
# OF DEPENDENTS
NCCI CLASS CODE
W
RATE
PER:
DAY
MONTH
# DAYS WORKED/WEEK
FULL PAY FOR DAY OF INJURY?
YES
NO
WEEK
OTHER:
DID SALARY CONTINUE?
TIME EMPLOYEE
AM
DATE OF INJURY/ILLNESS
TIME OF
LAST WORK
DATE EMPLOYER
DATE DISABILITY BEGAN
BEGAN WORK
OCCURRENC
DATE
NOTIFIED
PM
CONTACT NAME / PHONE NUMBER
TYPE OF INJURY/ILLNESS
PART OF BODY AFFECTED
DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES?
TYPE OF INJURY / ILLNESS CODE
PART OF BODY AFFECTED CODE
U
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE
ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN
OCCURRED
ACCIDENT OR ILLNESS EXPOSURE OCCURRED
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS
ILLNESS EXPOSURE OCCURRED
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.
CAUSE OF INJURY CODE
DATE RETURNED TO WORK
IF FATAL, GIVE DATE OF DEATH
WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?
WERE THEY USED?
T
PHYSICIAN / HEALTH CARE PROVIDER ( NAME & ADDRESS )
HOSPITAL ( NAME & ADDRESS )
INITIAL TREATMENT
NO MEDICAL TREATMENT
MINOR: BY EMPLOYER
MINOR CLINIC/HOSPITAL
EMERGENCY CARE
WITNESSES ( NAME & PHONE # )
HOSPITALIZED > 24 HRS
FUTURE MAJOR MEDICAL/
H
LOST TIME ANTICIPATED
DATE ADMINISTRATOR NOTIFIED
DATE PREPARED
PREPARER'S NAME & TITLE
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.
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).
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