Free D-38 - Nevada

State of Nevada

DEPARTMENT OF BUSINESS & INDUSTRY
DIVISION OF INDUSTRIAL RELATIONS
Workers' Compensation Section

This form must be completed IN FULL and SIGNED to be processed

INDEX OF CLAIMS SYSTEM CLAIM REGISTRATION/UPDATE/REQUEST DOCUMENT REGISTRATION REQUESTOR IS: Requestor Name INJURED EMPLOYEE SSN: Injured Employee Name:
Last First Middle Initial

UPDATE

REQUEST Self-Insured Employer Third-Party Administrator FEIN # Date Submitted:

Association of Self-Insured Employer Private Insurer

Sex: Male

Female

Birthdate:

Claim Type: Lost Time

Medical Only

Claim Number: Date Claim Closed Third-Party Administrator: Self-Insured Employer: Assoc. of Self-Insured Employer: Private Insurer: Private Insurer Address:
Street

Injury or Occupational Disease Date: Closure Pursuant To:
NRS 616C.235(1) NRS 616C.235(2)

Date ReOpened FEIN #: FEIN #: FEIN #: FEIN #

City

State

Zip

Policy Effective Date: Employer: Address:
Street

Policy Expiration Date: FEIN #
City State Zip

BODY PART CODE

BODY PART DESCRIPTION

Left, Right or Bilateral

BODY PART CODE

BODY PART DESCRIPTION

Left, Right or Bilateral

I hereby certify that the information contained on this form is true and correct. I also certify that I am a duly authorized representative of the requestor.

Signature

Date

D-38 (rev. 02/04)