Fill and Sign the Request for Hearing Uninsured Employer D 12bpdf Form

REQUEST FOR HEARING - UNINSURED EMPLOYER REPLY TO: Department of Administration OR Department of Administration Hearings Division - Appeals Officer Hearings Division - Appeals Officer 1050 E. William Street, Ste. 450 2200 S. Rancho Drive, Suite 220 Carson City, NV 89701 Las Vegas, NV 89102 (775) 687-8420 (702) 486-2525 Injured Employee's Name (Last, First, M.I.) Claim No. Address (P.O. Box/Apt./Street) City/State/Zip Code Telephone No. Date of Injury Employer's Name Account No. Address Employer's Phone No. City/State/Zip Code Employer's Representative I hereby request a hearing before the Appeals Officer to review the determination made by the Administrator of the Division of Industrial Relations regarding Employe r/Employee relationship in the designated claim above. The determination relates to (please mark appropriate space): Assignment of claim to the Uninsured Employers’ Claim Account Non-assignment of claim to Uninsured Employers’ Claim Account Briefly explain the basis for this appeal: ‰ The Injured Employee This request for hearing is filed by, or on behalf of: ‰The Employer and is dated this _________________ day of _____________________________, 20_____________. Signature of Injured Employee/Employer Injured Employee's/Employer's Rep. (Advisor) D-12b (Rev. 02/08)