Complaint Form (Northern Inusurers)
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Complaint Form (Northern Inusurers) Form. This is a Nevada form and can be use in Workers Comp.
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Tags: Complaint Form (Northern Inusurers), Nevada Workers Comp,
DEPARTMENT OF BUSINESS & INDUSTRY
DIVISION OF INDUSTRIAL RELATIONS
WORKERS’ COMPENSATION SECTION
400 West King Street, Suite 400
Carson City, Nevada 89703
Telephone: (775) 684-7270
Fax: (775) 687-6305
COMPLAINT FORM
Last Name
First Name
Home Address
City
Employer
Work Phone No.
Insurer/Third Party Administrator
Social Security No.
Address
State
Zip Code
Home Phone No.
Date of Injury
Claim No.
Phone Number
WHAT DO YOU WISH TO ACCOMPLISH WITH THIS COMPLAINT?
CIRCUMSTANCES LEADING YOU TO FILE THIS COMPLAINT:
Note: If additional space is required, please attach additional sheets, along with any available documentation.
I have contacted the Nevada Attorney for Injured Workers
I have contacted the Governor’s Office on Consumer Health.
COMPLAINANT’S SIGNATURE
DATE
Complaint form cc (Rev. 9/2005)
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