EMPLOYER TO AVOID PENALTY, THIS REPORT MUST BE COMPLETED AND MAILED TO THE INSURER WITHIN 6 WORKING DAYS OF RECEIPT OF THE C-4 FORM Employer’s Name Nature of Business (mfg., etc.) Office Mail Address Location . . . If different from mailing address Telephone Zip INSURER THIRD-PARTY ADMINISTRATOR Last Name Social Security City State EMPLOYEE First Name M.I. FEIN Sex City State Zip Birthdate Male Female In which state was employee hired? Marital Status Yes Single Primary Language Spoken Is the injured employee a corporate officer? . . . sole proprietor? No Yes (if applicable) Yes Divorced Widowed Department in which regularly employed: . . . partner? No Married How long has this person been employed by you in Nevada? No Employee’s occupation (job title) when hired or disabled Date of Injury (if applicable) Time of injury (Hours; Minute AM/PM) Was employee in your employ when injured or disabled Yes No by occupational disease (O/D)? No Date employer notified of injury or O/D Supervisor to whom injury or O/D reported Address or location of accident (Also provide city, county, state) (if applicable) Accident on employer’s premises? (if applicable) Yes No What was this employee doing when the accident occurred (loading truck, walking down stairs, etc.)? (if applicable) How did this injury or occupational disease occur? Include time employee began work. Be specific and answer in detail. Use additional sheet if necessary. Specify machine, tool, substance, or object most closely connected with the accident (if applicable) Was there more than one person injured in this accident? (if applicable) Witness Part of body injured or affected INJURY OR DISEASE Age Was the employee paid for the day of injury? (If applicable) Yes Witness If fatal, give date of death Nature of Injury or Occupational Disease (scratch, cut, bruise, strain, etc.) Yes Witness Did employee return to next scheduled shift after accident? (if applicable) Yes If validity of claim is doubted, state reason IMPORTANT Emergency Room How many days per week does employee work? S M T W Date employee was hired Was the employee hired to work 40 hours per week? Yes Will you have light duty work available if necessary? No Yes No Yes No Yes Hospitalized No Last day wages were earned From T F S am Rotating pm If not, for how many hours a week was the employee hired? To am pm Are you paying injured or disabled employee’s wages during disability? Last day of work after injury or disability No No Location of Initial Treatment Treating physician/chiropractor name Scheduled days off IMPORTANT LOST TIME INFO OSHA Log # Home Address (Number and Street) Telephone ACCIDENT OR DISEASE EMPLOYER’S REPORT OF INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE Please Type or Print Date of return to work Yes No Number of work days lost Did the employee receive unemployment compensation any time during the last 12 months? Yes No Do not know For the purpose of calculation of the average monthly wage, indicate the employee’s gross earnings by pay period for 12 weeks prior to the date of injury or disability. If the injured employee is expected to be off work 5 days or more, attach wage verification form (D-8). Gross earnings will include overtime, bonuses, and other remuneration, but will not include reimbursement for expenses. If the employee was employed by you for less than 12 weeks, provide gross earnings from the date of hire to the date of injury or disability. Pay period ends on: SUN MON TUE WED THUR FRI SAT Emloyee is paid: WEEKLY BI-WKLY MONTHLY OTHER SEMI-MONTHLY On the date of injury or disability the employee’s wage was: $ per Hr Day Wk Mo For assistance with Workers’ Compensation Issues you may contact the Office of the Governor Consumer Health Assistance Toll Free: 1-888-333-1597 Web site: http://govcha.state.nv.us E-mail cha@govcha.state.nv.us Insurer Use Only I affirm that the information provided above regarding the accident and injury or occupational disease is correct to the best of my knowledge. I further affirm the wage information provided is true and correct as taken from the payroll records of the employee in question. I also understand that providing false information is a violation of Nevada law. Claim is: Accepted Claims Examiner’s Signature Form C-3 (rev.11/05) Deferred rd Date Deemed Wage Account No. Class Code Date Denied Employer’s Signature and Title Status Clerk Date 3 Party ORIGINAL – EMPLOYER PAGE 2 – INSURER/TPA PAGE 3 – EMPLOYEE American LegalNet, Inc. www.USCourtForms.com