New Mexico Form Report PDF Details

The New Mexico Workers' Compensation Administration mandates the use of the Employers' First Report of Injury or Illness form to ensure meticulous documentation and timely reporting of workplace accidents or illnesses. Situated at 2410 Centre Ave. SE, Albuquerque, with additional offices statewide, this form serves as a vital tool in managing workers' compensation claims, underlining the importance of accuracy and detail in reporting. Employers must complete this form in black ink or type, providing comprehensive details about the employee involved, the nature of the injury or illness, and circumstances under which it occurred. The form covers a wide range of information, including employer and carrier details, the injured or ill employee’s personal and employment information, specifics about the injury or illness, treatment received, and witnesses, if any. It also prompts for the inclusion of codes relevant to the industry and injury type, underpinning the structured assessment and processing of the claim. This documentation is crucial not only for immediate medical response and compensation but also for improving workplace safety and prevention strategies. Employers are encouraged to fill in even the optional shaded areas for a fuller record that could be beneficial for internal use. Filing within the stiperset timelines and ensuring the provision of copies to all relevant parties, including the worker and the compensation insurer, is emphasized to avoid penalties. This form acts as neither an admission of liability nor a denial of the claim's compensability but as a foundational step in the workers' compensation process, ensuring all parties are adequately informed and rights are observed.

QuestionAnswer
Form NameNew Mexico Form Report
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesnew mexico hire report form, form mexico new report, new mexico first report of injury form, nm form compensation

Form Preview Example

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

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

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 )

A

C

 

 

TO

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

RA I

R

M

 

 

 

 

 

 

 

CHECK IF APPROPRIATE

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

SELF INSURANCE

 

 

 

 

 

 

 

 

 

 

 

I

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D

CARRIER FEIN

 

 

 

POLICY / SELF-INSURED NUMBER

 

 

 

 

ADMINISTRATOR FEIN

 

 

 

 

E

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

N

AGENT NAME & CODE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME ( LAST, FIRST, MIDDLE )

 

 

 

 

 

DATE OF BIRTH

SOCIAL SECURITY NUMBER

DATE HIRED

 

 

 

STATE OF HIRE

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS ( INCL ZIP )

 

 

 

 

 

 

GENDER

 

MARITAL STATUS

OCCUPATION/JOB TITLE OR (SOC)

P

 

 

 

 

 

 

 

 

 

MALE

 

 

UNMARRIED

CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SINGLE/DIVORCED

 

 

 

 

 

 

 

 

O

 

 

 

 

 

 

 

 

 

FEMALE

 

 

MARRIED

EMPLOYMENT STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

 

 

 

 

 

 

 

 

 

UNKNOWN

 

 

SEPARATED

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

PHONE NUMBER

 

 

 

 

 

 

# OF DEPENDENTS

 

UNKNOWN

NCCI CLASS CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

W

 

RATE

 

PER:

 

DAY

 

MONTH

# DAYS WORKED/WEEK

 

FULL PAY FOR DAY OF INJURY?

 

YES

 

NO

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G

 

 

 

 

 

WEEK

 

OTHER:

 

 

 

 

 

 

DID SALARY CONTINUE?

 

 

 

YES

 

NO

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TIME EMPLOYEE

AM

DATE OF INJURY/ILLNESS

TIME OF

 

 

AM

LAST WORK

 

DATE EMPLOYER

DATE DISABILITY BEGAN

 

 

BEGAN WORK

 

 

 

 

OCCURRENC

 

 

 

DATE

 

NOTIFIED

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

E

 

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

 

CONTACT NAME / PHONE NUMBER

 

 

 

 

 

TYPE OF INJURY/ILLNESS

 

 

 

PART OF BODY AFFECTED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

 

DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES?

 

TYPE OF INJURY / ILLNESS CODE

PART OF BODY AFFECTED CODE

 

 

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U

 

DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE

 

 

ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN

 

 

 

 

OCCURRED

 

 

 

 

 

 

 

ACCIDENT OR ILLNESS EXPOSURE OCCURRED

 

 

 

 

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR

WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS

R

 

ILLNESS EXPOSURE OCCURRED

 

 

 

 

 

 

EXPOSURE OCCURRED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

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?

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WERE THEY USED?

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

T

PHYSICIAN / HEALTH CARE PROVIDER ( NAME & ADDRESS )

 

 

HOSPITAL ( NAME & ADDRESS )

 

INITIAL TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

 

 

 

 

 

 

 

 

 

NO MEDICAL TREATMENT

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

 

 

 

 

 

 

 

 

MINOR: BY EMPLOYER

 

 

T

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

MINOR CLINIC/HOSPITAL

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N

 

 

 

 

 

 

 

 

 

EMERGENCY CARE

 

 

 

T

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O

WITNESSES ( NAME & PHONE # )

 

 

 

 

 

 

 

HOSPITALIZED > 24 HRS

 

 

 

 

 

 

 

 

 

 

 

FUTURE MAJOR MEDICAL/

 

 

T

 

 

 

 

 

 

 

 

 

 

 

H

 

 

 

 

 

 

 

 

 

LOST TIME ANTICIPATED

 

 

DATE ADMINISTRATOR NOTIFIED

 

DATE PREPARED

PREPARER'S NAME & TITLE

 

 

 

 

 

 

 

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).

How to Edit New Mexico Form Report Online for Free

Any time you need to fill out nm wca, you don't need to download and install any sort of software - simply make use of our online PDF editor. Our tool is consistently developing to grant the very best user experience attainable, and that is due to our resolve for continuous improvement and listening closely to customer feedback. To get the ball rolling, take these easy steps:

Step 1: First of all, access the editor by pressing the "Get Form Button" in the top section of this page.

Step 2: After you access the online editor, you will get the document all set to be filled out. Besides filling in different fields, you could also perform many other things with the Document, namely writing any words, changing the initial textual content, adding images, signing the form, and much more.

When it comes to blank fields of this particular form, this is what you should know:

1. You need to complete the nm wca properly, hence take care while filling out the segments containing these blank fields:

Part # 1 in filling out nm form compensation

2. The next part is to fill in all of the following blanks: OF DEPENDENTS, NCCI CLASS CODE, PHONE NUMBER, W A G E, RATE, PER, DAY WEEK, MONTH OTHER, DAYS WORKEDWEEK, FULL PAY FOR DAY OF INJURY DID, YES, YES, NO NO, TIME EMPLOYEE BEGAN WORK, and DATE OF INJURYILLNESS.

Completing segment 2 of nm form compensation

Always be really careful while completing DATE OF INJURYILLNESS and MONTH OTHER, because this is the part in which a lot of people make mistakes.

3. In this part, have a look at T R E A T M E N T, N HEALTH CARE PROVIDER NAME, PHYSICIA, NAME ADDRESS, HOSPITAL, WITNESSES NAME PHONE, DATE ADMINISTRATOR NOTIFIED, DATE PREPARED, PREPARERS NAME TITLE, INIT, IAL TREATMENT, NO MEDICAL TREATMENT MINOR BY, HOSPITALIZED HRS, FUTURE MAJOR MEDICAL LOST TIME, and NM WCA FORM E EQUIVALENT TO OSHAS. Every one of these will need to be completed with highest awareness of detail.

Find out how to prepare nm form compensation stage 3

Step 3: You should make sure your information is correct and then click on "Done" to continue further. Sign up with us right now and instantly get nm wca, prepared for downloading. Every edit made is handily kept , so that you can modify the document later on anytime. We don't share the information you use while completing forms at our site.

New Mexico Form Report isn’t the one you’re looking for?

Related Documents