INSURERS SUBSEQUENT INJURY CHECKLIST Notice to Insurer: This form must be completed and provided with all supporting documentation for claims submitted for reimbursement from the Subsequent Injury Account. PART ONE INJURED EMPLOYEE DATE OF INJURY CLAIM NUMBER INSURER THIRD-PARTY ADMINISTRATOR EMPLOYER SUBMITTED BY ASSOCIATION ADMINISTRATOR INITIAL REQUEST SUPPLEMENTAL REQUEST Please check and complete applicable blanks. All supporting documentation must be submitted in chronological order, oldest information on top. This information must be bound in a file folder and sectioned according to this form. Check one: Private Insurer Self-insured Employer Self-insured Association PART TWO DIR USE ONLY VERIFICATION Letter of application to the Subsequent Injury Account specifying the statute pertine nt to this application. PART THREE NRS 616B.557, 616B.578 OR 616B.587 a. Medical documentation specifically showing that compensation for disability is substantially greater due to the combined effects of the preexisting impairment than that which would have resulted from the subsequent injury alone. Doctor(s) providing medical documentation. Medical documentation of the preexisting permanent physical impairment of 6% or greater, including prior PPD evaluation, if available. Percentage Body Part Percentage Body Part Percentage Body Part Verification of the employers knowledge of impairment at the time of hire or retention in employment after obtaining knowledge of impairment. Date of hire Date of employers knowledge of impairment Date of retention in employment Notification of a possible claim against the Subsequent Injury Account, submitted within 100 weeks of the date of injury. Time lag wee ks. Lagtime weeks. D-37(1) rev. 12/03 >>>> 2 PART THREE (continued) DIR USE ONLY NRS 616B.557, 616B.578 OR 616B.587 b. Verification of false representation at the time of hire Date insurer became aware of the false representation. Notification of a possible claim against the Subsequent Injury Account submitted within 60 days of the date of the subsequent injury, or date the insurer learned of the false representation Time lag days . Lagtime days. PART FOUR Supporting Documentation Employers Report of Injury (Form C-3) Employees Claim for Compensation/Initial Report of Treatment (Form C-4) False representation (NRS 616B.560, 616B.581or 616B.590 only) PART FIVE Medical reporting regarding subsequent injury claim Medical documentation regarding preexisting impairment Permanent partial disability evaluation and calculation, subsequent injury claim PART SIX Wage verification and calculation Total expenditure documentation: Please provide calculator tapes for expenses requested. Printouts, log sheets, checks, etc., must be matched to the bill, explanation of benefits and/or rationale for payment in chronological order, oldest information on top. Computer printout(s) Payment log sheet(s) Copies of check(s) Copies of medical bills Explanation of benefits (EOB) Travel reimbursement, which must include cesopi of receipts and/or orders or requests for payments which specify the method of transportation; destination; mileage allowed; date(s) of travel; and per diem and/or lodging allowed. If any payment is made other than that shown, justification must be given. Other (specify) PART SEVEN Other Pertinent Document ation Insurer determinations and all documents from HO, AO, or District Court All vocational rehabilitation information Subrogation information Permanent Total information D-37(2) rev. 12/03 >>>> 3PART EIGHT TOTAL EXPENDITURES OF CLAIM MEDICAL Medical Treatment: Travel associated with medical care: Other (Specify) Total Medical: COMPENSATION Temporary Total Disability: Temporary Partial Disability: Permanent Partial Disability: Other (Specify) Total Compensation: VOCATIONAL REHABILITATION Maintenance: Schooling and/or Supplies: Counselor Services: Travel: Other (Specify) Total Rehabilitation: Other (Specify) Total Other: GRAND TOTAL EXPENDITURES: No administrative costs will be considered part of the claim pursuant to NAC 616B.707(2). These include, but are not limitedo, tutilization review services, attorney fees, cost of medical analysis or ratings conducted for the purpose of establishing a subsequent injury account, anany othed r administrative costs. D-37(3) rev. 12/03