Employees Claim For Compensation - Uninsured Employer {D-17}

EMPLOYEE'S CLAIM FOR COMPENSATION - UNINSURED EMPLOYER Mail to: DIVISION OF INDUSTRIAL RELATIONS SECTION 400 W. KING STREET, SUITE 400 OR 3360 W. SAHARA AVENUE, SUITE 250 Claim Number CARSON CITY NEVADA 89703 LAS VEGAS, NV 89102 EMPLOYEE First Name M.I. Last Name Soc. Sec. No. Birth Date Home Address (Number and Street) City State Zip Telephone Mailing Address Occupation (Job Title) Name of Immediate Supervisor Sex: Marital Status: No. of Dependents Union Affiliation Male [ ] Female [ ] Single [ ] Married [ ] Divorced [ ] Widow/er[ ] Date Hired Where Were You Hired? How Many Persons Are Employed In This Business? Names of Other Employees (Use Additional Sheets if Necessary) 1. 2. 3. EMPLOYER Owner's Name First M.I. Last Name Soc. Sec. No. Telephone Owner's Address Number and Street City State Zip Name of Business Business Address (Number and Street) City State Zip Telephone Nature of Business (Manufacturing, Etc.) ACCIDENT/OCCUPATIONAL DISEASE Date of Injury or Date You Hour of Injury (if applicable) Date Employer Notified of Learned of Disability and Its A.M. [ ] P.M. [ ] Injury/Occupational Disease Relationship to Your Employment Address Where The Accident Occurred (if applicable) What Were You Doing When Accident Occurred? (Loading Truck, Walking Down Stairs, Etc.) (if applicable) How Did Accident or Occupational Disease Occur? (Be Specific and in Detail; Use Additional Sheets if Necessary) Specify Machine, Tool, Substance, Condition or Object Most Closely Connected With Accident or Occupational Disease Nature of Injury or Occupational Disease (Scratch, Cut, Bruise, Etc.) Part(s) of Body Injured (if applicable) Side Injured (if applicable) To Whom Was Injury or Occupational Disease Reported? Right [ ] Left [ ] Both [ ] Were There Witnesses to Accident? (Give Names) (if applicable) Last Paid On Wage How Are You Paid? Cash [ ] Check [ ] $ per Did You Return to Next Scheduled Last Day Worked Date Returned To Work What Are Your Normal Work Days? Shift After Accident? Yes [ ] No [ ] TREATMENT Doctor Who Treated You for This Injury or Occupational Disease Doctor's Address Date of Visit Hour of Visit Were You Hospitalized? Yes [ ] No [ ] A.M. [ ] P.M. [ ] Name of Hospital Address of Hospital (if applicable) How Were You Transported From the Place of Accident Who Provided This Transportation? to the Place of Treatment (Car, Ambulance, Etc.)? I declare under penalty of perjury that the answers above are true and correct to the best of my knowledge. Date Signature I hereby elect to receive compensation under the provisions of chapters 616A to 616D, inclusive or chapter 617 of the Nevada Revised Statutes (NRS), and do by separate assignment, make an irrevocable assignment of subrogation pursuant to NRS 616C.215 to the Division of Industrial Relations. Date Signature D-17 (rev.06/18) American LegalNet, Inc. www.FormsWorkFlow.com