Fill and Sign the Injured Employees Request for Compensation Form

Claim Number INJURED EMPLOYEE' S REQUEST FOR COMPENSATION (Pursuant to NRS 616C. 475(6)) ANSWER ALL QUESTIONS, DATE, SIGN AND RETURN TO YOUR CLAIMS AGENT 1. Name: Social Security # Phone No: 2.Physical address: Street City State Zip Mailing address: Street/ P. O. Box City State Zip Is this a change of address? [ ] Yes [ ] No 3. Employer at time of injury: 4.Supervisor' s name: ________________________________ __________________ 5. Name of your attending physician or chiropractor: __ ___________________________________________________ ____ 6. Date on which you were last examined by attending p hysician or chiropractor: 7.Date of next appointment with physician or chiropra ctor: 8. a. Have you been released to return to work by you r attending physician or chiropractor? [ ] Yes [ ] No b. If so, give the date of release: 9. a. Have you returned to work with another employer ? [ ] Yes [ ] No b. Are you receiving payment from any employer? [ ] Yes [ ] No c. Date on which you returned to work: d. Name of employer for whom you returned to work: e. Address: 10.Have you been disabled and unable to work in any occupation for at least 5 consecutive days, or 5 cumulative d ays within a 20 day period? [ ] Yes [ ] No 11. Date on which you last worked: __________________ For Whom: ______________________________________ __ 12. When do you expect to be able to return to your reg ular occupation? 13.Would you be able to work at a light duty type job now? [ ] Yes [ ] No Comment: 14. Has your employer offered you a light duty type job ? [ ] Yes [ ] No a. If yes, when was the light duty job offered? Per NRS 616D. 300, I understand that the reporting o f false information may disqualify me from receiving workers' compensation benefits. Further, I understand falsification may subject me to civil and criminal penalties. I certify the above information is correct to the best of my knowledge. ________________________________ Date Signature CITY COUNTY STATE NOTE: An explanation of the methods used to calcul ate your average monthly wage and compensation bene fits should accompany your first compensation check. If you did not rece ive this, please contact your claims agent. FOR CLAIMS AGENT' S USE ONLY PAY: From ________________ To ___________________ Rev. date ____________ From ________________ To ___________________ TT Final TT TP Date Signature D-6 (Rev. 7/ 99)