Free D-44 - Nevada

Election of Coverage by Employer; and Employer Withdrawal of Election of Coverage
Pursuant to NRS 616B.656

Employer Name: Employer Address: Employer Telephone No.: Federal Identification No.: Employee Name: Employee Excluded Profession: Insurer: Date Notice Received to Administrator accepting provisions of NRS 616A to 616D. Effective Date: Date Notice to Insurer: Employer Representative Signature: Title: Date of Signature: Policy #:

Withdrawal of Employer Election Date Notice to Administrator: Date Notice to Insurer: Employer Representative Signature: Title: Date of Signature:

FOR WCS USE ONLY Method of Transmission First Class Mail [ Date Notice Received:
D-44 (Rev.02/04)

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Electronic Transmission/Fax [

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Personally Served [ ]