Employers Report Of Industrial Injury Or Occupational Disease {C-3}

Form C-3 - EMPLOYER’S REPORT OF INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE. This form is used in the State of Nevada to document and report a work-related injury or occupational disease to the employer’s workers’ compensation insurer. Employers are legally required to complete and submit this form within six working days of receiving a C-4 form (Physician’s Report of Injury) to avoid penalties. The purpose of the form is to gather detailed information about the employee, the incident or disease, and the employer’s insurance coverage to facilitate the processing of a workers’ compensation claim. The form collects essential data such as the employee’s name, address, social security number, date of birth, employment history, and specifics about the injury or occupational illness—including when and how it happened, what part of the body was affected, witnesses, and medical treatment details. It also requests information about the employee’s wages, work schedule, and whether light-duty or continued wage payments will be provided. Employers must affirm that all information, including wage data pulled from payroll records, is accurate, and sign the form under penalty of law. www.FormsWorkflow.com