Election Of Coverage By Employer And Employer Withdrawal Of Election Of Coverage {D-44} | Pdf Fpdf Doc Docx | Nevada

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Election Of Coverage By Employer And Employer Withdrawal Of Election Of Coverage {D-44} | Pdf Fpdf Doc Docx | Nevada

Election Of Coverage By Employer And Employer Withdrawal Of Election Of Coverage {D-44}

This is a Nevada form that can be used for Workers Comp.

Alternate TextLast updated: 5/17/2006

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Description

Election of Coverage by Employer; and Employer Withdrawal of Election of Coverage Pursuant to NRS 616B.656 Employer Name: Employer Address: Employer Telephone No.: Federal Identification No.: Employee Name: Employee Excluded Profession: Insurer: Date Notice Received to Administrator accepting provisions of NRS 616A to 616D. Effective Date: Policy #: Date Notice to Insurer: Employer Representative Signature: Title: Date of Signature: Withdrawal of Employer Election Date Notice to Administrator: Date Notice to Insurer: Employer Representative Signature: Title: Date of Signature: FOR WCS USE ONLY Method of Transmission First Class Mail [ ] Electronic Transmission/Fax [ ] Personally Served [ ] Date Notice Received: D-44 (Rev.02/04)

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