Index of Claims System 226 Claim Registration State of Nevada - Department of Business and Industry - Division of Industrial Relations - Workers222 Compensation Section ClaimNumber:ClaimType:CreateUpdate SUBMITTERINFORMATIONDateSubmittedtoWCS:FirstName:LastName:SubmitterPhoneNumber:Email: INJUREDEMPLOYEEINFORMATIONFirstName:MI:LastName:MaleFemaleDOB:ZipCode:UndocumentedSSN: CLAIMINFORMATIONDateofInjury/Disablement:C4ReceivedbyInsurer/TPA:Accepted/Denied:Accepted:TypeofLoss:Catastrophic:NatureofInjury:CauseofInjury:PermanentImpairment%:DeathDate:DeathResultofInjury:BenefitTypeBenefitStartBenefitEnd EMPLOYEREmployerName:EmployerFEIN:Phone:Address:City:State:Zip: INSURERInsurerName:InsurerFEIN:TPAName: CLAIMCLOSED/REOPENEDDateClaimClosed:NRSCloseCode:TotalCostatClosure:ReopenEffectiveDate:ReopenRequestDate:ReopenDecisionDate:ReopenDecision: PRIVATECARRIERINFORMATIONPolicyEffectiveDate:PolicyExpirationDate:PolicyNumber: INJURYINFORMATIONBodyPartCodeInjurySideAcceptedRated IncludeClaimHistoryReportHandwrittenFormswillnotbeacce p ted. American LegalNet, Inc. www.FormsWorkFlow.com