Nevada > Workers Comp
Index Of Claims System Claim Registration-Update-Request Document D-38 - Nevada
| Index Of Claims System Claim Registration-Update-Request Document Form. This is a Nevada form and can be used in Workers Comp . |
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This form must State of Nevada be completed IN DEPARTMENT OF BUSINESS & INDUSTRY FULL and SIGNED to be processed DIVISION OF INDUSTRIAL RELATIONS Workers Compensation Section INDEX OF CLAIMS SYSTEM CLAIM REGISTRATION/UPDATE/REQUEST DOCUMENT REGISTRATION UPDATE REQUEST REQUESTOR IS: Association of Self-Insured Employer Self-Insured Employer Private Insurer Third-Party Administrator Requestor Name FEIN # INJURED EMPLOYEE SSN : Date Submitted: Injured Employee Name: Last First Middle Initial Sex: Male Female Birthdate: Claim Type: Lost Time Medical Only Claim Number: Injury or Occupational Disease Date: Date Claim Closed Closure Pursuant To: NRS 616C.235(1) Date ReOpened NRS 616C.235(2) Third-Party Administrator: FEIN #: Self-Insured Employer: FEIN #: Assoc. of Self-Insured Employer: FEIN #: Private Insurer: FEIN # Private Insurer Address: Street City State Zip Policy Effective Date: Policy Expiration Date: Employer: FEIN # Address: Street City State Zip BODY PART BODY PART L eft, R ight BODY PART BODY PART L eft, R ight CODE DESCRIPTION or Bilateral CODE DESCRIPTION or Bilateral I hereby certify that the information contained on this formtrue and correct. I also certify is that I am a duly authorized representative of the requestor. Signature Date D-38 (rev. 02/04)
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