Index Of Claims System Claim Registration {D-38} | Pdf Fpdf Docx | Nevada

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Index Of Claims System Claim Registration {D-38} | Pdf Fpdf Docx | Nevada

Index Of Claims System Claim Registration {D-38}

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

Alternate TextLast updated: 4/9/2019

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Index of Claims System 226 Claim Registration State of Nevada - Department of Business and Industry - Division of Industrial Relations - Workers222 Compensation Section ClaimNumber:ClaimType:CreateUpdate SUBMITTERINFORMATIONDateSubmittedtoWCS:FirstName:LastName:SubmitterPhoneNumber:Email: INJUREDEMPLOYEEINFORMATIONFirstName:MI:LastName:MaleFemaleDOB:ZipCode:UndocumentedSSN: CLAIMINFORMATIONDateofInjury/Disablement:C4ReceivedbyInsurer/TPA:Accepted/Denied:Accepted:TypeofLoss:Catastrophic:NatureofInjury:CauseofInjury:PermanentImpairment%:DeathDate:DeathResultofInjury:BenefitTypeBenefitStartBenefitEnd EMPLOYEREmployerName:EmployerFEIN:Phone:Address:City:State:Zip: INSURERInsurerName:InsurerFEIN:TPAName: CLAIMCLOSED/REOPENEDDateClaimClosed:NRSCloseCode:TotalCostatClosure:ReopenEffectiveDate:ReopenRequestDate:ReopenDecisionDate:ReopenDecision: PRIVATECARRIERINFORMATIONPolicyEffectiveDate:PolicyExpirationDate:PolicyNumber: INJURYINFORMATIONBodyPartCodeInjurySideAcceptedRated IncludeClaimHistoryReportHandwrittenFormswillnotbeacce p ted. American LegalNet, Inc. www.FormsWorkFlow.com

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