Request For Hearing - Contested Claim {D-12a} | Pdf Fpdf Docx | Nevada

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Request For Hearing - Contested Claim {D-12a} | Pdf Fpdf Docx | Nevada

Request For Hearing - Contested Claim {D-12a}

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

Alternate TextLast updated: 4/9/2019

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REQUEST FOR HEARING - CONTESTED CLAIM (Pursuant to NAC 616C.274) REPLY TO: Department of Administration OR Department of Administration Hearings Division Hearings Division 1050 E. William Street, Ste. 400 2200 S. Rancho Drive, Suite 210 Carson City, NV 89701 Las Vegas, NV 89102 (775) 687-8440 (702) 486-2525 Employee Information Employer Information Em Claim No. Date of Injury Insurer Information Third - Party Administrator Information Third - Third - Do Not Complete or Mail This Form Unless You Disagree With the Insurer's Determination. PLEASE CHECK HERE IF YOUR REQUEST IS REGARDING A CLAIM FILED PURSUANT TO NRS 617.455 OR 617.457 YOU MUST INCLUDE A COPY OF THE DETERMINATION LETTER OR A HEARING WILL NOT BE SCHEDULED PURSUANT TO NRS 616C.315. Briefly explain the basis for this appeal: This request for hearing is filed by, or on behalf of: Injured Employee Employer and is dated this day of , 20. Signature of Injured Employee/Employer Injured Employee's/Employer's Rep. (Advisor) D-12a (Rev. 10/2018) American LegalNet, Inc. www.FormsWorkFlow.com

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