Fill and Sign the State of Nevada Department of Business Ampampamp Industry Division Form

State of Nevada DEPARTMENT OF BUSINESS & INDUSTRY DIVISION OF INDUSTRIAL RELATIONS Workers’ Compensation Section ASSIGNMENT TO DIVISION FOR WORKERS' COMPENSATION BENEFITS KNOW ALL MEN BY THESE PRESENTS: WHEREAS, I, the undersigned, sustained injuries by reason of an industrial accident; or incurred an occupational disease, arising out of and within the scope of my employment on the __________day of_____________________, 20______, while in the employ of ; and WHEREAS, said employer on said day had failed to provide mandatory industrial insurance coverage and was not certified as a self-insured employer or a member of an association of public or private employers by the Nevada Division of Insurance, as provided for under Chapters 616A to 616D, inclusive or chapter 617 of Nevada Revised Statutes (NRS); and WHEREAS, I have elected to receive compensation from the Uninsured Employer’s Claim Account, as provided for by Chapters 616A to 616D, inclusive, and chapter 617 of Nevada Revised Statutes; NOW, THEREFORE, in consideration of the payment of compensation to me, to which I may be entitled, I do hereby irrevocably assign and transfer to the Division of Industrial Relations for its proper use and benefit, a right to be subrogated to my rights pursuant to NRS 616C.215, against the above-named uninsured employer, or other responsible third-party, arising out of; relating to; or connected with the injuries sustained; or occupational disease incurred, as hereinabove set forth. AND I DO hereby irrevocably constitute and appoint the said Division of Industrial Relations, its successors and assigns, and in my name or otherwise, and for the sole use and benefit of the said Division of Industrial Relations, but at its own costs and expense, to demand; sue for; collect; receive or give acquittances for said claim or cause of action or any part thereof, against the said uninsured employer. IN WITNESS WHEREOF, I have executed the within and foregoing instrument on this day of _______________________, 20_____. Injured Employee Address Signed in the Presence of: Witness Witness D-18 (rev. 02/04)