Nevada > Workers Comp
Notice Of Claim Acceptance D-30 - Nevada
| Notice Of Claim Acceptance Form. This is a Nevada form and can be used in Workers Comp . |
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TO: R E: Claim No: Employer: Insurer: TPA: Date of Injury: Date of Notice: Body Part: NOTICE OF CLAIM ACCEPTANCE (Pursuant to NRS 616C.065) Dear The above referenced claim has been accepted on your behalf by (Insert Insurer Name). Please check the information contained on this notice. If you find any of the information to be incorrect, please notify the insurer handling the claim. If you disagree with the above determination, you mrequest a hearing before a Hearing Officer by ay completing the bottom portion of this notice within seventy (70) days after the date on which the notice was mailed, and sending it to the State of Nevada, Department of Administration, Hearings Division. Department of Administration OR Department of Administration Hearings Division Hearings Division 1050 E. William Street, Ste. 400 2200 S. Rancho Drive, Suite 210 Carson City, NV 89710 Las Vegas, NV 89102 (775) 687-5966 (702) 486-2525 Very truly yours, Reason for appeal: Signature D ate Retain a copy for your records c.: Enclosure D-30 (rev. 10/03)
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