Intent To Cancel, Renew Or Change To New Carrier Form
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Intent To Cancel, Renew Or Change To New Carrier Form. This is a Nevada form and can be use in Workers Comp.
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Tags: Intent To Cancel, Renew Or Change To New Carrier Form, D-42, Nevada Workers Comp,
INTENT TO CANCEL, RENEW OR
CHANGE TO NEW CARRIER FORM
Pursuant to NRS 616B.033 and NRS 616B.460
For Use By Private Carriers or Employers
Employer Name:
Business Address:
Business Telephone Number:
Federal Identification Number:
Current Insurer Name:
Insurer Address:
Business Telephone Number:
Policy Cancellation Date and Time:
Policy Number:
Policy Renewal Date and Time:
Policy Number:
New Insurer Name:
Insurer Address:
Business Telephone Number:
Policy Effective Date:
Policy Number:
Comments:
METHOD OF TRANSMISSION OF NOTICE - WCS USE ONLY
First Class Mail [ ]
Electronic Transmission/or Fax [ ]
Personally Served [ ]
Date and Time Notice Received:
D-42 (rev. 2/04)
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