Nevada C4 Employee Claim

C4 - Employee Name*
First Middle Last
C4 - Date Of Birth*
MM slash DD slash YYYY
C4 - What Is Your Sex?*
- Male
- Female
C4 - Claim Number*
C4 - Home Address*
Street Address Address Line 2 City State ZIP Code
C4 - What Is Your Age?*
C4 - What Is Your Height?*
C4 - What Is Your Weight?*
C4 - Social Security Number*
C4 - Employee Phone Number*
C4 - Mailing Address*
Street Address Address Line 2 City State ZIP Code
C4 - Primary Language Spoken*
C4 - Employee Insurer*
C4 - Third-Party Admin*
C4 - What Was Your Job Title When You Had Your Injury?*
C4 - Employer's Name*
C4 - Employer's Phone Number*
C4 - Office Mail Address*
Street Address Address Line 2 City State ZIP Code
C4 - Date Of Injury (if applicable)*
MM slash DD slash YYYY
C4 - Hours Injury (if applicable)*
- AM
- PM
C4 - Date Employer Notified*
MM slash DD slash YYYY
C4 - Last Day Of Work After Injury or Occupational Disease*
MM slash DD slash YYYY
C4 - Name Of Supervisor*
First Last
C4 - Location Of Accident*
Street Address Address Line 2 City State ZIP Code
C4 - What Were You Doing at the Time Of The Accident? (if applicable)*
C4 - How Did This Injury or Occupational Disease Occur? (Be specific and answer in detail)*
C4 - If You Believe That You Have an Occupational Disease, When Did You First Have Knowledge of the Disability and its Relationship to Your Employment?*
C4 - What Was The Nature Of Your Injury*
C4 - Body Part Affected*
C4 - Did You Have Any Witnesses To Your Accident?*
- Yes
- No
C4 - If Yes, How Many?*
- One
- Two
- Three
C4 - Witness 1*
First Last
C4 - Witness 2*
First Last
C4 - Witness 3
First Last
CERTIFY THAT THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND THAT I HAVE PROVIDED THIS INFORMATION IN ORDER TO OBTAIN THE BENEFITS OF NEVADA’S INDUSTRIAL INSURANCE AND OCCUPATIONAL DISEASES ACTS (NRS 616A TO 616D, INCLUSIVE OR CHAPTER 617 OF NRS). I HEREBY AUTHORIZE ANY PHYSICIAN, CHIROPRACTOR, SURGEON, PRACTITIONER, OR OTHER PERSON, ANY HOSPITAL, INCLUDING VETERANS ADMINISTRATION OR GOVERNMENTAL HOSPITAL, ANY MEDICAL SERVICE ORGANIZATION, ANY INSURANCE COMPANY, OR OTHER INSTITUTION OR ORGANIZATION TO RELEASE TO EACH OTHER, ANY MEDICAL OR OTHER INFORMATION, INCLUDING BENEFITS PAID OR PAYABLE, PERTINENT TO THIS INJURY OR DISEASE, EXCEPT INFORMATION RELATIVE TO DIAGNOSIS, TREATMENT AND/OR COUNSELING FOR AIDS, PSYCHOLOGICAL CONDITIONS, ALCOHOL OR CONTROLLED SUBSTANCES, FOR WHICH I MUST GIVE SPECIFIC AUTHORIZATION. A PHOTOSTAT OF THIS AUTHORIZATION SHALL BE AS VALID AS THE ORIGINAL.
C4 - Today's Date*
MM slash DD slash YYYY
C4 - Place*
C4 - Employee's Signature*
Comments
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