Request For Hearing - Uninsured Employer
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Request For Hearing - Uninsured Employer Form. This is a Nevada form and can be use in Workers Comp.
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Tags: Request For Hearing - Uninsured Employer, D-12b, Nevada Workers Comp,
REQUEST FOR HEARING - UNINSURED EMPLOYER
REPLY TO:
Department of Administration
Hearings Division - Appeals Officer
1050 E. William Street, Ste. 450
Carson City, NV 89701
(775) 687-8420
OR
Department of Administration
Hearings Division - Appeals Officer
2200 S. Rancho Drive, Suite 220
Las Vegas, NV 89102
(702) 486-2525
Injured Employee's Name (Last, First, M.I.)
Claim No.
Address (P.O. Box/Apt./Street)
City/State/Zip Code
Telephone No.
Date of Injury
Employer's Name
Account No.
Address
Employer's Phone No.
City/State/Zip Code
Employer's Representative
I hereby request a hearing before the Appeals Officer to review the determination made by the Administrator of
the Division of Industrial Relations regarding Employer/Employee relationship in the designated claim above.
The determination relates to (please mark appropriate space):
Assignment of claim to the Uninsured Employers’ Claim Account
Non-assignment of claim to Uninsured Employers’ Claim Account
Briefly explain the basis for this appeal:
The Injured Employee
This request for hearing is filed by, or on behalf of:
The Employer
and is dated this _________________ day of _____________________________, 20_____________.
Signature of Injured Employee/Employer
Injured Employee's/Employer's Rep. (Advisor)
D-12b (Rev. 02/08)
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