Fill and Sign the D 16 Worddoc Form

State of Nevada DEPARTMENT OF BUSINESS & INDUSTRY DIVISION OF INDUSTRIAL RELATIONS Workers’ Compensation Section INJURED EMPLOYEE SOCIAL SECURITY NO. EMPLOYER DATE OF INJURY NOTICE OF ELECTION FOR COMPENSATION BENEFITS UNDER THE UNINSURED EMPLOYER STATUTES OPTION 1: Complete the D-17 (Employee's Claim For Compensation - Uninsured Employer) and D-18 (Assignment to Division For Workers' Compensation Benefits). If you elect this option, the Division of Industrial Relations will assign your claim to a claims administrator to determine whether you have a compensable injury or disease. Since your employer did not maintain workers' compensation insurance, the entire cost of the assigned claim may be paid from the uninsured employers' claim account. Your employer at the time of the injury or accident will be billed for all costs. To make an election to receive compensation under the provisions of chapters 616A to 617, inclusive, of the Nevada Revised Statutes (NRS), you must make an irrevocable assignment of subrogation rights pursuant to NRS 616C.215 to the Division of Industrial Relations. OPTION 2: You have the right to make the necessary arrangements with your employer for the payment of benefits incurred as a result of your industrial accident or disease. If you elect this option there will be no involvement by the Division of Industrial Relations, or any other claims administrator and the responsibility of handling your medical costs and compensation benefits will be assumed by you, the injured employee. An injured employee may take legal action against an uninsured employer for losses arising from a work-related accident or disease. If you receive any compensation benefits from the uninsured employer's claim account, your assignment of subrogation rights allows the Division to file a lien against any money you receive from any party. Benefits paid to you may be recovered by the Division from any judgement, award or settlement you may receive. If you select Option 2, you cannot change your mind to choose Option 1 at a later time. I fully understand the options enumerated above and have had each method explained to me by a representative of the Division of Industrial Relations, and understand further, that my election is irrevocable. I elect Option Signature Date D-16 (rev.02/04)