| Title |
Last Updated |
| Request For Hearing - Contested Claim |
April 9, 2019 |
| Occupational Disease Claim Report |
April 9, 2019 |
| Notice Of Claim Acceptance |
April 9, 2019 |
| Informational Poster - Displayed By Employer |
September 25, 2018 |
| Reaffirmation Retraction Of Lump Sum Request |
July 16, 2018 |
| Notice Of Election For Compensation Benefits Under Uninsured Employer Statutes |
July 16, 2018 |
| Injured Employees Request For Compensation |
July 16, 2018 |
| Fatality Report |
July 16, 2018 |
| Employees Claim For Compensation - Uninsured Employer |
July 16, 2018 |
| Complaint Form (Southern Insurers) |
July 16, 2018 |
| Request For Rotating Rating Physician Or Chiropractor |
June 14, 2018 |
| Sample Letter |
November 30, 2016 |
| Firemen And Police Officers Lung Examination Form |
November 30, 2016 |
| Firemen Police Officers Extensive Heart Examination Form |
November 30, 2016 |
| Firemen Police Officers Hearing Examination Form |
November 30, 2016 |
| Firemen And Police Officers Medical History Form |
November 30, 2016 |
| Permanent Partial Disability Award Calculation Work Sheet |
July 11, 2012 |
| Permanent Partial Disability Award Calculation Work Sheet For Disability Over 25 Percent Body Basis |
July 11, 2012 |
| Employers Wage Verification Form |
December 2, 2010 |
| Notice Of Intention To Close Claim |
December 2, 2010 |
| Election Of Method Of Payment Of Compensation |
December 2, 2010 |
| Permanent Work Related Mental Impairment Rating Report Work Sheet |
November 12, 2010 |
| Temporary Partial Disability Calculation Worksheet |
May 21, 2009 |
| Workers Compensation Proof of Coverage |
April 20, 2009 |
| Wage Calculation Form For Claims Agents Use |
April 20, 2009 |
| Physician And Chiropractor Progress Report Certification Of Disability |
April 20, 2009 |
| Rehabilitation Lump Sum Request |
April 20, 2009 |
| Permanent Total Disability Report Of Employment |
April 20, 2009 |
| Interest Calculation For Compensation Due |
April 16, 2009 |
| Lump Sum Rehabilitation Agreement |
April 16, 2009 |
| Firemen Police Officers Limited Heart Examination Form |
April 16, 2009 |
| Health Insurance Claim Form |
April 16, 2009 |
| Employees Declaration Of Election To Report Tips |
April 16, 2009 |
| Election Of Method Of Payment Of Compensation For Disability Greater Than 25 |
April 16, 2009 |
| Employees Claim For Compensation Report Of Initial Treatment |
April 16, 2009 |
| Complaint Form (Northern Inusurers) |
December 1, 2008 |
| Intent To Cancel, Renew Or Change To New Carrier Form |
December 1, 2008 |
| Policy Termination-Cancelation-Reinstatement Notice |
August 21, 2008 |
| Request For Hearing - Uninsured Employer |
August 15, 2008 |
| Request For Additional Medical Information And Release Form |
February 12, 2008 |
| Election For Nevada Workers Compensation Coverage For Out Of State Injury |
October 11, 2006 |
| Request For Reimbursement Of Expenses For Travel And Lost Wages |
October 11, 2006 |
| Proof Of Coverage Notice |
August 7, 2006 |
| Employers Report Of Industrial Injury Or Occupational Disease |
May 24, 2006 |
| Industrial Insurance Regulation Section Noncompliance Premium - Las Vegas |
May 24, 2006 |
| Industrial Insurance Regulation Section Noncompliance Premium - Carson City |
May 24, 2006 |
| Notice Of Injury Or Occupational Disease Incident Report |
May 24, 2006 |
| Sole Proprietor Coverage |
May 17, 2006 |
| Employees Election To Reject Coverage And Election To Waive Rejection Of Coverage For Excluded Persons |
May 17, 2006 |
| Insurers Subsequent Injury Checklist |
May 17, 2006 |
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