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Form |
Description |
| c-3.pdf | Employer's Report of Industrial Injury or Occupational Disease. - 5/10 |
| c-1.pdf | Notice of Injury or Occupational Disease (Incident Report). - 10/05 |
| c-4.pdf | Employee's Claim for Compensation / Report of Initial Treatment. - 7/10 |
| d-1.pdf | POSTER - Informational Poster - Displayed by Employer - 11 x 17 Size - 10/07 |
| d-2.pdf | BROCHURE - Brief Description of Your Rights and Benefits if You Are Injured on the Job. - 10/07 |
| d-5.pdf | Wage Calculation Form for Claims Agent's Use. - 7/99 |
| d-6.pdf | Injured Employee's Request for Compensation. - 7/99 |
| d-7.pdf | Explanation of Wage Calculation. - 7/99 |
| d-8.pdf | Employer's Wage Verification Form. - 10/10 |
| d-9a.pdf | Permanent Partial Disability Award Calculation Worksheet. - 1/12 |
| d-9b.pdf | Permanent Partial Disability Award Calculation Worksheet for Disability Over 25 Percent Body Basis. - 1/12 |
| d-9c.pdf | Permanent Work-Related Mental Impairment Rating Report Work Sheet - 6/10 |
| d-10a.pdf | Election of Method of Payment of Compensation. - 10/10 |
| d-10b.pdf | Election of Method of Payment of Compensation for Disability Greater than 25 Percent. - 7/99 |
| d-11.pdf | Reaffirmation of Lump Sum Request. - 7/99 |
| d-12a.pdf | Request for Hearing - Contested Claim. - 12/07 |
| d-12b.pdf | Request for Hearing - Uninsured Employer. - 2/08 |
| d-13.pdf | Injured Employee's Right to Reopen a Claim Which Has Been Closed. - 7/99 |
| d-14.pdf | Permanent Total Disability Report of Employment. - 7/99 |
| d-15.pdf | Election for Nevada Workers' Compensation Coverage for Out-of-State Injury. - 7/99 |
| d-16.pdf | Notice of Election for Compensation Benefits Under the Uninsured Employer Statutes. - 2/04 |
| d-17.pdf | Employee's Claim for Compensation - Uninsured Employer. - 2/04 |
| d-18.pdf | Assignment of Claim for Workers' Compensation - Uninsured Employer. - 2/04 |
| d-21.pdf | Fatality Report. - 7/99 |
| d-22.pdf | BROCHURE - Notice to Employees - Tip Information. - 7/99 |
| d-23.pdf | Employee's Declaration of Election to Report Tips. - 7/99 |
| d-24.pdf | Request for Reimbursement of Expenses for Travel and Lost Wages. - 6/06 |
| d-25.pdf | Affirmation of Compliance with Mandatory Industrial Insurance Requirements. - 3/01 |
| d-26.pdf | Application for Reimbursement of Claim-Related Travel Expenses. - 4/04 |
| d-27.pdf | Interest Calculation for Compensation Due. - 7/99 |
| d-28.pdf | Rehabilitation Lump Sum Request. - 7/99 |
| d-29.pdf | Lump Sum Rehabilitation Agreement. - 7/99 |
| d-30.pdf | Notice of Claim Acceptance. - 5/10 |
| d-31.pdf | Notice of Intention to Close Claim. - 10/10 |
| d-32.pdf | Authorization Request for Additional Chiropractic Treatment. - 7/99 |
| d-33.pdf | Authorization Request for Additional Physical Therapy Treatment. - 7/99 |
| d-34.pdf | Health Care Financing Administration 1500 Billing Form. - 12/90 |
| d-35.pdf | Request for a Rotating Rating Physician or Chiropractor. - 4/11 |
| d-36.pdf | Request for Additional Medical Information and Medical Release. - 12/07 |
| d-37.pdf | Insurer's Subsequent Injury Checklist. - 12/03 |
| d-38.pdf | Injured Worker Index System Claims Registration Document. - 2/04 |
| d-39.pdf | Physician's Progress Report - Certification of Disability. - 7/99 |
| d-43.pdf | Employee's Election to Reject Coverage and Election to Waive the Rejection of Coverage for Excluded Persons. - 2/04 |
| d-44.pdf | Election of Coverage by Employer; Employer Withdrawal of Election of Coverage. - 2/04 |
| d-45.pdf | Sole Proprietor Coverage. - 2/04 |
| d-46.pdf | Temporary Partial Disability Calculation Worksheet. - 7/99 |
| d-48.pdf | Proof of Coverage Notice. - 5/97 |
| d-49.pdf | Information Page. - 1991 |
| d-50.pdf | Policy Termination, Cancellation and Reinstatement Notice. - 8/98 |
| d-52.pdf | Alternative Choice of Physician or Chiropractor and Referral to a Specialist. - 7/09 |
| d-53.pdf | Special Note Regarding D-53, UB-04 - N/D |
| od-1.pdf | Firemen and Police Officers' Medical History Form. - 7/99 |
| od-2.pdf | Firemen and Police Officers' Lung Examination Form. - 7/99 |
| od-3.pdf | Firemen and Police Officers' Extensive Heart Examination Form. - 7/99 |
| od-4.pdf | Firemen and Police Officers' Limited Heart Examination Form. - 7/99 |
| od-5.pdf | Firemen and Police Officers' Hearing Examination Form. - 7/99 |
| od-6.pdf | Firemen and Police Officers' Sample Letter. - 7/99 |
| od-7.pdf | Information Regarding Physical Examinations for Firemen and Police Officers. - 7/99 |
| od-8.pdf | Occupational Disease Claim Report - 6/06 |
| SurvivingSpouse.pdf | Surviving Spouse Remarriage Report Death Claims – Nrs 616c.505 Response Due By: June 1, 2010 - 4/10 |
| SurvivingSpouse_Instructions.pdf | Instructions for Surviving Spouse Claim Form - 4/10 |
| employee.pdf | BROCHURE - Employee's Guide - 8/11 |
| spanish.pdf | BROCHURE - Employee's Guide SPANISH - 8/10 |
| employer.pdf | BROCHURE - Employer's Guide - 8/11 |
| expect.pdf | EMPLOYERS: What Should I expect from my insurer? - 8/08 |
| regs.pdf | Poster Regulations - 8/08 |
| engqa.pdf | Basic Q&A about NV WC System - 8/08 |
| spanqa.pdf | Basic Q&A about NV WC System SPANISH- 8/08 |
| timeframes.pdf | Claims Processing Time Frames - 2/13 |
| contacts.pdf | Who to Contact - 10/08 |