NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION

EMPLOYERS' FIRST REPORT OF INJURY OR ILLNESS

 Do Not Enter Data In Shaded Cells
                                 
PO BOX 27198
ALBUQUERQUE, NM 87125-7198
PLEASE PRINT IN BLACK INK OR TYPE - PLEASE FILL IN ALL APPLICABLE FIELDS
GENERAL INFORMATION:
REPORT PURPOSE:
EMPLOYER NAME:    EMPLOYER'S LOCATION ADDRESS (IF DIFFERENT)
ADDRESS: ADDRESS:
CITY: CITY:
STATE: STATE:
ZIP: ZIP:
SIC CODE: PHONE#:
EMPLOYER FEIN:
CARRIER: CLAIMS ADMINISTRATION
CARRIER NAME: CLAIMS ADMINISTRATOR NAME: KEENAN & ASSOCIATES, INC.
ADDRESS: ADDRESS: PO BOX 14590
C/ST/ZIP: C/ST/ZIP: ALBUQUERQUE, NM 87191-4590
CARRIER FEIN: PHONE#: (505) 293-6600
SELF INSURED: ADMINISTRATOR FEIN: 85-0193025
EMPLOYEE
FIRST NAME: DATE OF BIRTH GENDER:
LAST NAME:
MIDDLE INITIAL: SOCIAL SECURITY NUMBER: MARITAL STATUS:
ADDRESS:
C/ST/ZIP: DATE HIRED: OCCUPATION/JOB TITLE:
PHONE: STATE OF HIRE: EMPLOYEE STATUS
WAGE
WAGE: WAGE PERIOD: # OF DAYS WORKED/WEEK FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE?
$
OCCURRENCE:
TIME EMPLOYEE BEGAN WORK: TIME OF OCCURRENCE:
DATE OF INJURY/ILLNESS: LAST WORK DATE: DATE EMPLOYER NOTIFIED: DATE DISABILITY BEGAN:
CONTACT NAME: CONTACT PHONE #: DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES:
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
150 CHARACTER LIMIT, BE CONCISE
ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
150 CHARACTER LIMIT, BE CONCISE 
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
150 CHARACTER LIMIT, BE CONCISE
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.
150 CHARACTER LIMIT, BE CONCISE
DATE RETURNED TO WORK: IF FATAL, GIVE DATE OF DEATH: WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? WHERE THEY USED?
TREATMENT
PHYSICIAN/HEALTHCARE PROVIDER NAME: HOSPITAL NAME:
ADDRESS ADDRESS:
C/ST/ZIP C/ST/ZIP:
INITIAL TREATMENT:
OTHER
PREPARER'S NAME:
WITNESS NAME: DATE ADMINISTRATOR NOTIFIED: DATE PREPARED: PREPARER'S PHONE:
WITNESS PHONE#: PREPARER'S TITLE:
 

 
*THE FOLLOWING FIELDS IF DATA AVAILABLE:
CARRIER/ADMINISTRATOR CLAIM #: POLICY/SELF-INSURED #:
LOCATION #: # OF DEPENDENTS:
POLICY EFFECTIVE DATE: NCCI CLASS CODE:
POSTAL CODE OF INJURY SITE:

 

 

 

**THE FOLLOWING FIELDS FOR CLAIMS ADMINISTRATOR ONLY:
 

 

CAUSE OF INJURY CODES:

 
I. BURN OR SCALD - HEAT OR COLD EXPOSURE:
I. CAUGHT IN OR BETWEEN:
III. CUT, PUNCTURE, SCRAPE INJURED BY:
IV. FALL OR SLIP INJURY:
V. MOTOR VEHICLE:
VI. STRAIN OR INJURY BY:
VII. STRIKING AGAINST OR STEPPING ON:
VIII. STRUCK OR INJURED BY:
IX. MISCELLANEOUS CAUSES:

    

NATURE OF INJURY CODES:

 
I. SPECIFIC INJURY:
II. OCCUPATIONAL DISEASE OR COMMUNICABLE  INJURY:
III. MULTIPLE INJURIES:

 

 

PARTS OF THE BODY CODES:

 
I. HEAD:
II. NECK:
III. UPPER EXTREMITIES:
IV. TRUNK:
V. LOWER EXTREMITIES:
VI. MULTIPLE BODY PARTS:
 

 
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