NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION 
  
 EMPLOYERS' FIRST REPORT OF INJURY OR ILLNESS                                                                                                                                         
  
 2410 CENTRE AVE. SE  ¤PO BOX 27198                                                                                                                                                     OFFICIAL USE ONLY 
 ALBUQUERQUE, NM 87125-7198 
  
 PLEASE      PRINTEMPLOYER  IN BLACK( NAME INK& ORADDRESS TYPE.INCL ZIP )                                            CARRIER / ADMINISTRATOR CLAIM #                  OSHA LOG NUMBER            REPORT PURPOSE CODE 
                                                                                                                                                                                                            
  G                                                                                                                   JURISDICTION                                    JURISDICTION      CLAIM NUMBER 
  E                                                                                                                                                                              
                                                                                                                     
  N                                                                                                                 INSURED REPORT NUMBER 
  E                                                                                                                  
  R                                                                                                                 EMPLOYER'S            LOCATION ADDRESS  ( IF DIFFERENT )             LOCATION # 
  A          PHONE NUMBER                                                                                                                                                                           
                                                                EMPLOYER FEIN                                                                                                           INDUSTRY CODE 
  L                                                                                                                                                                                                
                                                                                                                                                            
             CARRIER     ( NAME,  ADDRESS  &  PHONE NO )                                                            POLICY   PERIOD                        CLAIMS ADMINISTRATOR  ( NAME,  ADDRESS  &  PHONE NO ) 
  C                                                                                                                                                         
            
  A        C                                                                                                                  TO                                      
           L                                                                                                         
  R        A                                                                                                         
           I                                                                                                          
  R        M                                                                                                        CHECK   SELF IF APPROPRIATE INSURANCE 
           S 
            
    I      A CARRIER     FEIN                                                                 POLICY  / SELF-INSURED NUMBER                                            ADMINISTRATOR FEIN 
           D 
  E        M                                                                                                                                                                     
           I  
           N 
  R          AGENT NAME & CODE NUMBER 
                        
  E          NAME  ( LAST,  FIRST,  MIDDLE )                                                                        DATE OF BIRTH  SOCIAL SECURITY NUMBER                         DATE  HIRED                       STATE OF HIRE 
                                                                                                                                                                                                                               
        M    ADDRESS ( INCL ZIP )                                                                                   GENDER                         MARITAL   STATUS               OCCUPATION/JOB TITLE OR (SOC) CODE 
  P                                                                                                                      MALE                              UNMARRIED                         
  L                                                                                                                                                         SINGLE/DIVORCED        
                                                                                                                         FEMALE                            MARRIED                EMPLOYMENT STATUS 
  O                                                                                                                                                                                          
  Y                                                                                                                      UNKNOWN                           SEPARATED 
  E          PHONE    NUMBER                                                                                        # OF DEPENDENTS                                                NCCI CLASS CODE 
                                                                                                                                                           UNKNOWN 
  E                                                                                                                                                                                          
                                                                                                               
  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                                                AM           DATE OF INJURY/ILLNESS                   TIME OF                     AM   LAST WORK          DATE EMPLOYER NOTIFIED              DATE DISABILITY         BEGAN 
             TIME EMPLOYEE                                                                               OCCURRENC                        DATE                                                    
                                                                                                                                      
             BEGAN WORK                            PM                                                                                PM                                                                     
  O                                                
                                                                                                                                                                                   
  C          CONTACT NAME / PHONE NUMBER                                                                            TYPE  OF  INJURY/ILLNESS                                      PART  OF  BODY AFFECTED             
                                                                                                                                                                                             
  C                                                                                                                 TYPE OF INJURY / ILLNESS CODE                                 PART OF BODY AFFECTED CODE 
             DID INJURY/ILLNESS EXPOSURE            YESOCCUR ON EMPLOYER'S                  PREMISES? NO                                                                                     
                                                                                             
  U          DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED                                          ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN 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 
  N          DIRECTLY    INJURED THE  EMPLOYEE OR MADE THE EMPLOYEE ILL. 
                                                                                                                                                                                                  
                                                                                                                                                                                                 CAUSE OF INJURY CODE 
  C                                                                                                                                                                                               
                                                                                                                                                                                                                                      
                                                                                                                                                                                                                               NO 
  E          DATE  RETURNED TO WORK                IF FATAL, GIVE DATE OF DEATH                         WEREWERE THEYSAFEGUARDSUSED? OR SAFETY EQUIPMENT PROVIDED?                                   YESYES                           
                                                                                                                    
                                                                                                                                                                                                                               NO 
  
  T          PHYSICIAN     / HEALTH CARE PROVIDER  ( NAME  &  ADDRESS )                                              HOSPITAL ( NAME  &  ADDRESS )                                       INITIAL  TREATMENT 
  R                                                                                                                                                                                              NO MEDICAL TREATMENT 
  E 
  A                                                                                                                                                                                               
  T                                                                                                                                                                                              MINOR: BY EMPLOYER 
  M                                                                                                                                                                                               
  E                                                                                                                                                                                              MINOR CLINIC/HOSPITAL 
  TN                                                                                                                                                                                              
                                                                                                                                                                                                 EMERGENCY CARE 
                                                                                                                                                                                                  
  O          WITNESSES  ( NAME  &  PHONE # )                                                                                                                                                     HOSPITALIZED > 24 HRS 
                                                                                                                                                                                                  
  T                                                                                                                                                                                              FUTURE MAJOR MEDICAL/ 
                                                                                                                                                                                                 LOST TIME ANTICIPATED 
  H                                                                                                            
  E          DATE ADMINISTRATOR NOTIFIED                                                   DATE PREPARED      PREPARER'S NAME & TITLE 
  R                                                                                                                      
                                                                                                               
 NM WCA FORM E1.2                                                EQUIVALENT TO OSHA'S FORM 301                                                                                    FORM IA-1 (7/02)  ÓIAIABC 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:  599-9746/1-800-568-7310                                                                           LAS CRUCES:  524-6246/1-800-870-6826 
 LAS                              VEGAS:     454-9251/1-800-281-7889                                           LOVINGTON:   396-3437/1-800-934-2450 
                                                    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).