WebWorkers' Compensation & Occupational Accident Claims > ... New Mexico; New Mexico. Notices. State-Specific Workers' Compensation Notice – English & Spanish; State-Specific Forms. First Report of Injury (NM WCA Form E1.2) ... Medical Records Certification; Submit completed forms to Protective Insurance Company: Email: claimreporting ... WebJan 1, 2016 · Please submit this claim form within 28 days of the date the employer is informed of the accident via email to [email protected] or fax 702-796-1330. Kansas Claim Form — Employee Authorization for Medical Treatment (170-367) (Rev. 3-2024)
Claims Process New Mexico Workers Compensation …
WebYour employer should have these forms readily available for you. This form should be completed within fifteen (15) days or sooner. Your employer must also sign and date this … WebPlease use the form below to submit a vehicle accident or vandalism. ACCIDENT DETAILS Date of Loss: Location of Accident or Incident: Description of Accident or Incident: VEHICLE INFORMATION Vehicle (Year, Make & Model): License Plate Number: Driver Name: Driver License Number * Current DDC Max. file size: 1,000 MB. Phone: Agency: phillip suber fdle
Report a Vehicle Accident NM GSD
WebDisplaying the Notice of Accident form in a noticeable place. Following the workers’ compensation safety inspection requirements. With workers’ comp coverage comes an assessment fee. You’ll have to pay it if you’re carrying this coverage for your business, and the fee is $2.30 for each employee per calender quarter. WebThis completed form, together with the itemized bills, should be submitted to: Blue Cross and Blue Shield of New Mexico P.O. Box 27630 Albuquerque, New Mexico 87125-7630 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 478158.1015 Claim … WebNotice of Accident or Occupational Disease Disablement Poster (Form NOA-1-W) The following forms need to be completed and submitted to EMPLOYERS when a work-related … phillips\u0027 colon health capsules 30 capsules