DEPARTMENT OF BUSINESS & INDUSTRY DIVISION OF INDUSTRIAL RELATIONS/ 3360 West Sahara Ave., Suite 250, Las Vegas, NV 89102 Telephone: (702) 486-9000 or (702) 486-9080 Fax: (702) 486-8712 COMPLAINT FORM Last Name First Name Social Security No. Home Address City State Zip Code Home Phone No. Employer Work Phone No. Date of Injury Claim No. Insurer/Third Party Administrator Address 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 Office of Consumer Health Assistance. DATE Complaint form lv (Rev. 6/2018) American LegalNet, Inc. www.FormsWorkFlow.com