Fill and Sign the Justia Employers Report of Industrial Injury or Legal Forms

TO AVOID PENALTY, THIS REPORT MUST BE COMPLETED AND MAILED TO THE INSURER WITHIN 6 WORKING DAYS OF RECEIPT OF THE C-4 FORM Please Type or Print EMPLOYER’S REPORT OF INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE Employer’s Name Nature of Business (mfg., etc.) FEIN OSHA Log # Office Mail Address Location . . . If different from mailing address Telephone EMPLOYER City State Zip INSURER THIRD-PARTY ADMINISTRATOR First Name M.I. Last Name Social Security Birthdate Age Primary Language Spoken Home Address (Number and Street) Sex … Male … Female Marital Status … Single … Married … Divorced … Widowed City State Zip Was the employee paid for the day of injury? (If applicable) … Yes … No How long has this person been employed by you in Nevada? In which state was employee hired? Employee’s occupation (job title) when hired or disabled Department in which regularly employed: EMPLOYEE Telephone Is the injured employee a corporate officer? . . . sole proprietor? . . . partner? … Yes … No … Yes … No … Yes … No Was employee in your employ when injured or disabled by occupational disease (O/D)? … Yes … No Date of Injury (if applicable) Time of injury (Hours; Minute AM/PM) (if applicable) Date employer notified of injury or O/D Supervisor to whom injury or O/D reported Address or location of accident (Also provide city, county, state) (if applicable) Accident on employer’s premises? (if applicable) … Yes … No What was this employee doing when the accident occurred (l oading truck, walking down stairs, etc.)? (if applicable) ACCIDENT OR DISEASE How did this injury or occupational disease occur? Include ti me employee began work. Be specific and answer in detail. Use additional sheet if necessary. Specify machine, tool, substance, or objec t most closely connected with the accident (if applicable) Witness Part of body injured or affected If fatal, give date of death Witness Witness Was there more than one person injured in this accident? (if applicable) … Yes … No Nature of Injury or Occupational Disease (scratch, cut, bruise, strain, etc.) Did employee return to next scheduled shift after accident? (if applicable) … Yes … No Will you have light duty work available if necessary? … Yes … No If validity of claim is doubted, state reason Location of Initial Treatment Treating physician/chiropractor name Emergency Room … Yes … No Hospitalized … Yes … No IMPORTANT How many days per week does employee work? From … am … pm To … am … pm Last day wages were earned INJURY OR DISEASE Scheduled S M T W T F S Rotating days off … … … … … … … … Are you paying injured or disabled employee’s wages during disability ? … Yes … No Date employee was hired Last day of work after injury or dis ability Date of return to work Number of work days lost Was the employee hired to If not, for how many hours a week work 40 hours per week? … Yes … No was the employee hired? Did the employee receive unemployment compensation any time during the last 12 months? … Yes … No … Do not know For the purpose of calculation of the average monthly wage, indi cate the employee’s gross earnings by pay period for 12 weeks p rior to the date of injury or disability. If the injured employee is expected to be off work 5 days or more, attach wage verification form (D-8). Gross earnings will include overtime, bonuses, and other remuneration, but will not include reimbursement for expenses. If the employee was employed by you for less than 12 weeks, provide gross earnings from the date of hire to the date of injury or disability. IMPORTANT LOST TIME INFO Pay period … SUN … TUE … THUR … SAT ends on: … MON … WED … FRI Emloyee … WEEKLY … MONTHLY … OTHER is paid: … BI-WKLY … SEMI-MONTHLY On the date of injury or disability the employee’s wage was: $ per … Hr … Day … Wk … Mo For assistance with Workers’ Compensation Issues you may contact the Offi ce of the Governor Consumer Health Assistance Toll Free : 1-888-333-1597 Web site : http://govcha.state.nv.us E-mail cha@govcha.state.nv.us Ë I affirm that the information provided above regarding the accident and injury or occupational disease is correct to the best of my knowledge. I further affirm the wage information provided is true and correct as taken from the payroll records of the employee in question. I also understand that providing false information is a violation of Nevada law. Employer’s Signature and Title Date Claim is: … Accepted … Denied … Deferred … 3rd Party Deemed Wage Account No. Class Code Insurer Use Only Claims Examiner’s Signature Date Status Clerk Date Form C-3 (rev.11/05) ORIGINAL – EMPLOYER PAGE 2 – INSURER/TPA PAGE 3 – EMPLOYEE