Request For Hearing - Uninsured Employer {D-12b}

REQUEST FOR HEARING - UNINSURED EMPLOYER REPLY TO: Department of Administration OR Department of Administration Hearings Division - Appeals Officer Hearings Division - Appeals Officer 1050 E. William Street, Ste. 450 2200 S. Rancho Drive, Suite 210 Carson City, NV 89701 Las Vegas, NV 89102 (775) 687-5289 (702) 486-2525 Injured Employees Name (Last, First, M.I.) C laim No. Address (P.O. Box/Apt./Street) City/State/Zip Code Telephone No. Date of Injury Employers Name Account No. Address Employers Phone No. City/State/Zip Code Employers Representative I hereby request a hearing before the Appeals Officer to review the determination made by the Administrator of the Division of Industrial Relations regarding Employer/Employee relationship in the designated claim above. The determination relates to (please mark appropriate space): Assignment of claim to the Uninsured Employers Claim Account Non-assignment of claim to Uninsured Employers Claim Account Briefly explain the basis for this appeal: The Injured Employee This request for hearing is filed by, or on behalf of: The Employer and is dated this _________________ day of _____________________________, 20_____________. Signature of Injured Employee/Employer Injured Employees/Employers Rep. (Advisor) D-12b (Rev. 10/03)