Claim Number INJURED EMPLOYEE'S REQUEST FOR COMPENSATION Pursuant to NRS 616C.475(6) ANSWER ALL QUESTIONS, DATE, SIGN AND RETURN TO YOUR CLAIMS AGENT 1. Name: Social Security # Phone No: 2. Physical address: Street City State Zip Mailing address: Street/P.O.Box City State Zip Is this a change of address? [ ] Yes [ ] NoEmployer at time of injury: 3. Supervisor's name: 4. Name of your attending physician or chiropractor: 5. Date on which you were last examined by attending physician or chiropractor: 6. Date of next appointment with physician or chiropractor: 7. a. Have you been released to return to work by your attending physician or chiropractor? [ ] Yes [ ] No b. If so, give the date of release: 8. a. Have you returned to work with another employer? [ ] Yes [ ] No b. Are you receiving payment from any employer? [ ] Yes [ ] No c. Date on which you returned to work: d. Name of employer for whom you returned to work: e. Address: 9. Have you been disabled and unable to work in any occupation for at least 5 consecutive days, or 5 cumulative days within a 20 day period? [ ] Yes [ ] No 10. Date on which you last worked: For Whom: 11. When do you expect to be able to return to your regular occupation? 12. Would you be able to work at a light duty type job now? [ ] Yes [ ] No Comment: 13. Has your employer offered you a light duty type job? [ ] Yes [ ] No a. If yes, when was the light duty job offered? Per NRS 616D.300, I understand that the reporting of false information may disqualify me from receiving workers' compensation benefits. Further, I understand falsification may subject me to civil and criminal penalties. I certify the above information is correct to the best of my knowledge. Date Signature CITY COUNTY STATE NOTE: An explanation of the methods used to calculate your average monthly wage and compensation benefits should accompany your first compensation check. If you did not receive this, please contact your claims agent. FOR CLAIMS AGENT'S USE ONLY PAY: From To From To Rev. date TT Final TT TP Date Signature D-6 (Rev. 7/99) American LegalNet, Inc. www.FormsWorkFlow.com