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Carson City, Nevada  89703
Telephone:  (775) 684-7260
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WORKERS' COMPENSATION FORMS

NCCI FORMS ARE AVAILABLE AT THE FOLLOWING LINK:   NCCI

The following forms are provided via the Internet in .pdf format for your convenience. You will need Adobe Acrobat Reader, a free utility, to view and print the forms. If you do not have this utility, please download it from Get Acrobat Reader: and install it before trying to view the forms.

To help you in using the forms, the Workers' Compensation Section has simply quoted below the Nevada Administrative Codes that cover forms here. Please print this page out for your ready reference.

Posters and Forms

NAC 616A.460 Informational poster to be displayed by employers. (NRS 616A.400, 616A.490)

1. Each employer governed by the provisions of chapters 616A to 617, inclusive, of NRS shall prominently display at his place of business a poster with the language and in the format specified in Form D-1.

2. The title of the poster must be printed in not less than 20-point bold type. The required statement concerning questions and problems relating to claims must be printed in not less than 12-point bold type. The text appearing on the remainder of the poster must be printed in not less than 10-point type. The poster must be at least 11 inches by 17 inches in size.

3. Each employer shall:

(a) Display the poster as required by this section; and
(b) Advise his employees of the name, business address and telephone number of his insurer's or third-party administrator's adjuster in this state that is located nearest to the employer's place of business for their claims for workers' compensation.

4. The poster must be displayed in such a manner as to be readily visible by all employees. A poster must not be displayed unless it has been issued or approved by the Workers' Compensation Section.

(Added to NAC by Div. of Industrial Insurance Regulation, eff. 2-22-88; A 8-30-91; A by Div. of Industrial Relations, 3-28-94; R093-98, 12-18-98; R093-98, 12-18-98, eff. 7-1-99)

NAC 616A.470 Poster to be displayed by employers with employees who receive tips.

1. Each employer governed by the provisions of chapters 616A to 617, inclusive, of NRS who has employees who receive tips shall prominently display a poster with the language and in the format specified in Form D-22.

2. The poster must be at least 8 1/2 inches by 11 inches in size and posted in such a manner as to be readily visible by all employees. (Added to NAC by Div. of Industrial Insurance Regulation, eff. 2-22-88; A by Div. of Industrial Relations, 3-28-94)-(Substituted in revision for NAC 616.255)

NAC616A.480 Use, alteration, printing and distribution of certain posters and forms. (NRS 616A.400, 616A.417)

1. The following posters and forms or data must be used by an insurer, employer, injured employee, provider of health care, organization for managed care or third-party administrator in the administration of claims for workers' compensation:

(a) D-1, Informational Poster - Displayed by Employer. The informational poster must include the language contained in Form D-2, and the name, business address, telephone number and contact person of:

(1) The insurer;
(2) The third-party administrator, if applicable;
(3) The organization for managed care or providers of health care with whom the insurer has contracted to provide medical and health care services, if applicable; and
(4) The name, business address and telephone number of the insurer's or third-party administrator's adjuster in this state that is located nearest to the employer's place of business.

(b) D-2, Brief Description of Your Rights and Benefits if You Are Injured on the Job.

(c) C-1, Notice of Injury or Occupational Disease (Incident Report). One copy of the form must be delivered to the injured employee, and one copy of the form must be retained by the employer. The language contained in Form D-2 must be printed on the reverse side of the employee's copy of the form, or provided to the employee as a separate document with an affirmative statement acknowledging receipt.

(d) C-3, Employer's Report of Industrial Injury or Occupational Disease. A copy of the form must be delivered to or the form must be filed by electronic transmission with the insurer or third-party administrator. The form signed by the employer must be retained by the employer. A copy of the form must be delivered to the injured employee. If the employer files the form by electronic transmission, the employer must:

(1) Transmit all fields of the form that are required to be completed, as prescribed by the administrator.
(2) Sign the form with an electronic symbol representing the signature of the employer that is:

(I) Unique to the employer;
(II) Capable of verification; and
(III) Linked to data in such a manner that the signature is invalidated if the data is altered.

(3) Acknowledge on the form that he will maintain the original report of industrial injury or occupational disease for 3 years. If the employer moves from or ceases operation in this state, the employer shall deliver the original form to the insurer for inclusion in the insurer's file on the injured employee within 30 days after the move or cessation of operation.

(e) C-4, Employee's Claim for Compensation/Report of Initial Treatment. A copy of the form must be delivered to the insurer or third-party administrator. A copy of the form must be delivered to or the form must be filed by electronic transmission with the employer. A copy of the form must be delivered to the injured employee. The language contained in Form D-2 must be printed on the reverse side of the injured employee's copy of the form or provided to the injured employee as a separate document with an affirmative statement acknowledging receipt. The original form signed by the injured employee and the physician or chiropractor who conducted the initial examination of the injured employee must be retained by that physician or chiropractor. If the physician or chiropractor who conducted the initial examination files the form by electronic transmission, the physician or chiropractor must:

(1) Transmit all fields of the form that are required to be completed, as prescribed by the administrator.
(2) Sign the form with an electronic symbol representing the signature of the physician or chiropractor that is:

(I) Unique to the physician or chiropractor;
(II) Capable of verification; and
(III) Linked to data in such a manner that the signature is invalidated if the data is altered.

(3) Acknowledge on the form that he will maintain the original form for the claim for compensation for 3 years. If the physician or chiropractor who conducted the initial examination moves from or ceases treating patients in this state, the physician or chiropractor shall deliver the original form to the insurer for inclusion in the insurer's file on the injured employee within 30 days after the move or cessation of treatment of patients.

(f) D-5, Wage Calculation Form for Claims Agent's Use.
(g) D-6, Injured Employee's Request for Compensation.
(h) D-7, Explanation of Wage Calculation.
(i) D-8, Employer's Wage Verification Form.
(j) D-9(a), Permanent Partial Disability Award Calculation Worksheet.
(k) D-9(b), Permanent Partial Disability Award Calculation Worksheet for Disability Over 25 Percent Body Basis.
(l) D-9(c). Permanent Partial Disability Worksheet for Stress Claims Pursuant to NRS 616c.180.
(m) D-10(a), Election of Method of Payment of Compensation.
(n) D-10(b), Election of Method of Payment of Compensation for Disability Greater than 25 Percent.
(o) D-11, Reaffirmation/Retraction of Lump Sum Request.
(p) D-12(a), Request for Hearing - Contested Claim.
(q) D-12(b), Request for Hearing - Uninsured Employer.
(r) D-13, Injured Employee's Right to Reopen a Claim Which Has Been Closed.
(s) D-14, Permanent Total Disability Report of Employment.
(t) D-15, Election for Nevada Workers' Compensation Coverage for Out-of-State Injury.
(u) D-16, Notice of Election for Compensation Benefits Under the Uninsured Employer Statutes.
(v) D-17, Employee's Claim for Compensation - Uninsured Employer.
(w) D-18, Assignment of Claim for Workers' Compensation - Uninsured Employer.
(x) D-21, Fatality Report.
(y) D-22, Notice to Employees - Tip Information.
(z) D-23, Employee's Declaration of Election to Report Tips.
(aa) D-24, Request for Reimbursement of Expenses for Travel and Lost Wages.
(bb) D-25, Affirmation of Compliance with Mandatory Industrial Insurance Requirements.
(cc) D-26, Application for Reimbursement of Claim-Related Travel Expenses.
(dd) D-27, Interest Calculation for Compensation Due.
(ee) D-28, Rehabilitation Lump Sum Request.
(ff) D-29, Lump Sum Rehabilitation Agreement.
(gg) D-30, Notice of Claim Acceptance.
(hh) D-31, Notice of Intention to Close Claim.
(ii) D-32, Authorization Request for Additional Chiropractic Treatment.
(jj) D-33, Authorization Request for Additional Physical Therapy Treatment.
(kk) D-34, CMS 1500 Billing Form.
(ll) D-35, Request for a Rotating Rating Physician or Chiropractor.
(mm) D-36, Request for Additional Medical Information and Medical Release.
(nn) D-37, Insurer's Subsequent Injury Checklist.
(oo) D-38, Injured Worker Index System Claims Registration Document.
(pp) D-39, Physician's Progress Report - Certification of Disability.
(qq) D-43, Employee's Election to Reject Coverage and Election to Waive the Rejection of Coverage for Excluded Persons.
(rr) D-44, Election of Coverage by Employer; Employer Withdrawal of Election of Coverage.
(ss) D-45, Sole Proprietor Coverage.
(tt) D-46, Temporary Partial Disability Calculation Worksheet.
(uu) D-48, Proof of Coverage Notice.
(vv) D-49, Information Page.
(ww) D-50, Policy Termination, Cancellation and Reinstatement Notice.
(xx)
D-52, Alternative Choice of Physician or Chiropractor.
(
 (NRS 616C.090).
(yy) D-53, Special Note

2. In addition to the forms specified in subsection 1, the following forms must be used by each insurer in the administration of a claim for an occupational disease:

(a) OD-1, Firemen and Police Officers' Medical History Form.
(b) OD-2, Firemen and Police Officers' Lung Examination Form.
(c) OD-3, Firemen and Police Officers' Extensive Heart Examination Form.
(d) OD-4, Firemen and Police Officers' Limited Heart Examination Form.
(e) OD-5, Firemen and Police Officers' Hearing Examination Form.
(f) OD-6, Firemen and Police Officers' Sample Letter.
(g) OD-7, Information Regarding Physical Examinations for Firemen and Police Officers.
(h)
OD-8, Occupational Disease Claim Report

3. The forms listed in this section must be accurately completed, including, without limitation, a signature and a date if required by the form. An insurer or employer may designate a third-party administrator as an agent to sign any form listed in this section.

4. An insurer, employer, injured employee, provider of health care, organization for managed care or third-party administrator may not use a different form or change a form without the prior written approval of the administrator.

5. The Workers' Compensation Section will be responsible for printing and distributing the following forms:

(a) C-4, Employee's Claim for Compensation/Report of Initial Treatment;
(b) D-12(b), Request for Hearing - Uninsured Employer;
(c) D-16, Notice of Election for Compensation Benefits Under the Uninsured Employer Statutes;
(d) D-17, Employee's Claim for Compensation - Uninsured Employer; and
(e) D-18, Assignment of Claim for Workers' Compensation - Uninsured Employer.

6. Each insurer or third-party administrator is responsible for printing and distributing all other forms listed in this section. The provisions of this subsection do not prohibit an insurer, employer, provider of health care, organization for managed care or third-party administrator from providing any form listed in this section.

7. Upon the request of the administrator, an insurer, employer, provider of health care, organization for managed care or third-party administrator shall submit to the administrator a copy of any form used in this state by the insurer, employer, provider of health care, organization for managed care or third-party administrator in the administration of claims for workers' compensation.

(Added to NAC by Div. of Industrial Insurance Regulation, eff. 2-22-88; A by Div. of Industrial Relations, 3-28-94; R104-97, 3-6-98; R098-98, 12-18-98; R093-98, 12-18-98; R093-98, 12-18-98, eff. 7-1-99; R071-99, 10-29-99; R105-00, 1-18-2001, eff. 3-1-2001)

 
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Last Updated: 10/23/13 04:01:38 PM