Index Of Claims System Claim Registration-Update-Request Document
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Index Of Claims System Claim Registration-Update-Request Document Form. This is a Nevada form and can be use in Workers Comp.
Tags: Index Of Claims System Claim Registration-Update-Request Document, D-38, Nevada Workers Comp,
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
State of Nevada
DEPARTMENT OF BUSINESS & INDUSTRY
DIVISION OF INDUSTRIAL RELATIONS No.
Workers’ Compensation Section
This form must
be completed IN
FULL and SIGNED
to be processed
-against- INDEX OF CLAIMS SYSTEM
CLAIM REGISTRATION/UPDATE/REQUEST DOCUMENT
REQUESTOR .IS:. . . . . . .Association. of .Self-Insured. Employer. . . . . . Self-Insured Employer
......... .. .......... ........
THE PEOPLE OF THE STATE OF NEW YORK
INJURED EMPLOYEE SSN:
Injured Employee Name:
Claim Type: Lost Time
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
Injury or Occupational Disease Date:
, on the
, To: ,NRS 616C.235(1) in the ReOpened and at any recessed
or adjourned date, to testify and give evidence as a witness in this 616C.235(2) part of the
action on the
Self-Insured Employer: to comply with this subpoena is punishable as a contempt of FEINand will make you liable to
Assoc. of Self-Insured Employer: subpoena was issued for a maximum penalty of $50 and all damages sustained as a
the party on whose behalf this
Privateresult of your failure to comply.
Private Insurer Address:
Witness, Honorable Street
Policy Effective Date:
, one of the Justices of the
Policy Expiration Date:
(Attorney must sign above and type name below)
Office and P.O. Address
I hereby certify that the information contained on this form is true and correct. I also certify that I am a duly authorized
representative of the requestor.
Date Mobile Tel. No.:
D-38 (rev. 02/04)
American LegalNet, Inc.