This area is only available to WorkCompResearch subscribers. WCR offers the most advanced Compliance and Regulatory Research System available.

Already a member? Log-in

Join Today for Immediate Access!


Sign Up


Home| Forms| Legal Library| Compliance| Calculators| State Comparisons| Reference Desk| What's New| Roundtable
Pre-select A State ↓ (Optional)   Current State: None   (← what's this?)

Nevada Form Center -

Type & Print Forms - programmed for direct type and print functionality.

Each form may be downloaded in Adobe Acrobat format. Download the form by clicking on the form number below.
If you do not have Adobe Acrobat Reader, you may download it here for free. Download Adobe Here

All of these forms may now be auto-populated from your claims software program! Click here to learn about FlashForm SSL.


Form

Description

c-3.pdf Employer's Report of Industrial Injury or Occupational Disease
c-1.pdf Notice of Injury or Occupational Disease (Incident Report)
c-4.pdf Employee's Claim for Compensation / Report of Initial Treatment
d-1.pdf POSTER - Informational Poster - Displayed by Employer - 11 x 17 Size
d-2.pdf BROCHURE -Brief Description of Your Rights and Benefits if You Are Injured on the Job
d-5.pdf Wage Calculation Form for Claims Agent's Use
d-6.pdf Injured Employee's Request for Compensation
d-7.pdf Explanation of Wage Calculation
d-8.pdf Employer's Wage Verification Form
d-9a.pdf Permanent Partial Disability Award Calculation Worksheet
d-9b.pdf Permanent Partial Disability Award Calculation Worksheet for Disability Over 25 Percent Body Basis
d-9c.pdf Permanent Work-Related Mental Impairment Rating Report Work Sheet
d-10a.pdf Election of Method of Payment of Compensation
d-10b.pdf Election of Method of Payment of Compensation for Disability Greater than 25 Percent
d-11.pdf Reaffirmation of Lump Sum Request
d-12a.pdf Request for Hearing - Contested Claim
d-12b.pdf Request for Hearing - Uninsured Employer
d-13.pdf Injured Employee's Right to Reopen a Claim Which Has Been Closed
d-14.pdf Permanent Total Disability Report of Employment
d-15.pdf Election for Nevada Workers' Compensation Coverage for Out-of-State Injury
d-16.pdf Notice of Election for Compensation Benefits Under the Uninsured Employer Statutes
d-17.pdf Employee's Claim for Compensation - Uninsured Employer
d-18.pdf Assignment of Claim for Workers' Compensation - Uninsured Employer
d-21.pdf Fatality Report
d-22.pdf BROCHURE - Notice to Employees - Tip Information
d-23.pdf Employee's Declaration of Election to Report Tips
d-24.pdf Request for Reimbursement of Expenses for Travel and Lost Wages
d-25.pdf Affirmation of Compliance with Mandatory Industrial Insurance Requirements
d-26.pdf Application for Reimbursement of Claim-Related Travel Expenses
d-27.pdf Interest Calculation for Compensation Due
d-28.pdf Rehabilitation Lump Sum Request
d-29.pdf Lump Sum Rehabilitation Agreement
d-30.pdf Notice of Claim Acceptance
d-31.pdf Notice of Intention to Close Claim
d-32.pdf Authorization Request for Additional Chiropractic Treatment
d-33.pdf Authorization Request for Additional Physical Therapy Treatment
d-34.pdf Health Care Financing Administration 1500 Billing Form
d-35.pdf Request for a Rotating Rating Physician or Chiropractor
d-36.pdf Request for Additional Medical Information and Medical Release
d-37.pdf Insurer's Subsequent Injury Checklist
d-38.pdf Injured Worker Index System Claims Registration Document
d-39.pdf Physician's Progress Report - Certification of Disability
d-43.pdf Employee's Election to Reject Coverage and Election to Waive the Rejection of Coverage for Excluded Persons
d-44.pdf Election of Coverage by Employer; Employer Withdrawal of Election of Coverage
d-45.pdf Sole Proprietor Coverage
d-46.pdf Temporary Partial Disability Calculation Worksheet
d-48.pdf Proof of Coverage Notice
d-49.pdf Information Page
d-50.pdf Policy Termination, Cancellation and Reinstatement Notice
d-53.pdf Alternative Choice of Physician or Chiropractor
reptform.pdf 2016 Permanent Total (PT) Claim Reporting Form
PTD_reqltr.pdf 2016 Permanent Total (PT) Claim Reporting Instructions
deathbenefits.pdf Death Benefit Claims (NRS 616C.505) Reporting Form
od-1.pdf Firemen and Police Officers' Medical History Form
od-2.pdf Firemen and Police Officers' Lung Examination Form
od-3.pdf Firemen and Police Officers' Extensive Heart Examination Form
od-4.pdf Firemen and Police Officers' Limited Heart Examination Form
od-5.pdf Firemen and Police Officers' Hearing Examination Form
od-6.pdf Firemen and Police Officers' Sample Letter
od-7.pdf Information Regarding Physical Examinations for Firemen and Police Officers
raoccdis.pdf OD-8 Reporting Requirements
od-8.pdf Occupational Disease Claim Report
employee.pdf BROCHURE - Employee's Guide
spanish.pdf BROCHURE - Employee's Guide (Spanish)
employer.pdf BROCHURE - Employer's Guide
expect.pdf EMPLOYERS: What Should I expect from my insurer?
regs.pdf Poster Regulations
employerfaq.pdf Employer Frequently Asked Questions
timeframes.pdf Claims Processing Time Frames
contacts.pdf Who to Contact
TPA_DataRequestForm.pdf FY16 TPA Information Form (After July 10,2017, must be filed via CARDS Web Portal)
insurerinfo.pdf FY 16 Insurer Information Form (After July 10,2017, must be filed via CARDS Web Portal)