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Last updated: 12/1/2008
Complaint Form (Northern Inusurers)
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Description
DEPARTMENT OF BUSINESS & INDUSTRY DIVISION OF INDUSTRIAL RELATIONS WORKERS' COMPENSATION SECTION 400 West King Street, Suite 400 Carson City, Nevada 89703 Telephone: (775) 684-7270 Fax: (775) 687-6305 COMPLAINT FORM Last Name First Name Social Security No. Home Address City State Zip Code Home Phone No. Employer Work Phone No. Date of Injury Claim No. Insurer/Third Party Administrator Address Phone Number WHAT DO YOU WISH TO ACCOMPLISH WITH THIS COMPLAINT? CIRCUMSTANCES LEADING YOU TO FILE THIS COMPLAINT: Note: If additional space is required, please attach additional sheets, along with any available documentation. I have contacted the Nevada Attorney for Injured Workers I have contacted the Governor's Office on Consumer Health. COMPLAINANT'S SIGNATURE DATE Complaint form cc (Rev. 9/2005) American LegalNet, Inc. www.FormsWorkflow.com
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