Fill and Sign the Index of Claims System Claim Registration Nevada Form

Index of Claims System – Claim Registration State of Nevada - Department of Business and Industry - Division of Industrial Relations - Workers’ Compensation Section ,KHDUE\FHUWLI\WKDWWKHLQIRUPDWLRQFRQWDLQHGRQWKLVIRUPLVWUXHDQGFRUUHFW,DOVRFHUWLI\WKDW,DPDGXO\DXWKRUL]HGUHSUHVHQWDWLYHRIWKH6XEPLWWHU BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 6LJQ'DWH '5HY Claim Number: Claim Type: Create Update SUBMITTER INFORMATION Date Submitted to WCS: FirstName: Last Name: Submitter Phone Number: Email: INJURED EMPLOYEE INFORMATION First Name: MI: Last Name: Male Female DOB: Zip Code: Undocumented SSN: CLAIM INFORMATION Date of Injury/Disablement: C4 Received by Insurer/TPA: Accepted/Denied: Accepted: Type of Loss: Catastrophic: Nature of Injury: Cause of Injury: Permanent Impairment %: Death Date: Death Result of Injury: Benefit Type Benefit Start Benefit End EMPLOYER Employer Name: Employer FEIN: Phone: Address: City: State: Zip: INSURER Insurer Name: Insurer FEIN: TPA Name: CLAIM CLOSED/REOPENED Date Claim Closed: NRS Close Code: Total Cost at Closure: Reopen Effective Date: Reopen Request Date: Reopen Decision Date: Reopen Decision: PRIVATE CARRIER INFORMATION Policy Effective Date: Policy Expiration Date: Policy Number: INJURY INFORMATION Body Part Code Injury Side Accepted Rated Include Claim History Report Handwritten Forms will not be acce pted.