2011-12 New Mexico Self Insurers’ Fund Board of Trustees

The League organized and administers the New Mexico Self Insurers’ Fund, which offers Workers’ Compensation, general liability, law enforcement, civil rights, errors and omissions, auto liability, auto physical damage, and property and volunteer coverage to its members. The Fund also offers group health, medical and life insurance.

Included in this page are two forms commonly used by the Fund, a Notice of Tort Claim and IRS Form W-9, Request for Taxpayer Identification Number and Certification. Also included is a Class Code Glossary of Workers’ Compensation Terms, the Fund’s Liability Policy and the Fund’s Workers’ Compensation Policy. Each of these documents are in PDF format. These documents may be printed for your convenience.

PLEASE NOTE: If you are faxing any material concerning claims or underwriting to the Self Insurers’ Fund, please use the following fax number: (505) 820-0670.

Workers’ Compensation Glossary

Workers’ Compensation Policy

Liability Policy

Experience Modifier FAQ

Sample Safety Training Matrices (large file, may take time to load)

Workers’ Compensation Premium Allocation

NMSIF  FORMS

Equipment Addition/Deletion Form

Property Additon/Deletion Form

Auto Addition/Deletion Form

Certificate of Insurance Request Form

Employer’s First Report of Injury or Illness (e-1)

HIPAA Complaint Medical Release Form

Choice of Health Care Provider Form

Notice of Accident Form

Election of Benefits Form

Mileage Reimbursement Request

Notice of Tort Claim Form

IRS Form W-9

2013 Annual Safety Training Log

Workers’ Compensation Average Weekly Wage Worksheet