Free - Nevada

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
Nature of Business (mfg., etc.)

EMPLOYER'S REPORT OF INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE
FEIN OSHA Log # Telephone THIRD-PARTY ADMINISTRATOR Birthdate Age Primary Language Spoken

EMPLOYER

Employer's Name Office Mail Address City First Name M.I. State Zip Last Name

Location . . . If different from mailing address INSURER Social Security

EMPLOYEE

Home Address (Number and Street) Sex City State Zip Male Female Marital Status Single Married Divorced Widowed

Was the employee paid for the day of injury?
(If applicable)

Yes

No

How long has this person been employed by you in Nevada? Department in which regularly employed: Was employee in your employ when injured or disabled Yes No by occupational disease (O/D)? Supervisor to whom injury or O/D reported Accident on employer's premises? (if applicable)

In which state was employee hired? Telephone

Employee's occupation (job title) when hired or disabled
. . . sole proprietor? Yes
(if applicable)

Is the injured employee a corporate officer? Yes No

. . . partner? Yes No

No

Date of Injury (if applicable) Time of injury (Hours; Minute AM/PM)

Date employer notified of injury or O/D

ACCIDENT OR DISEASE

Address or location of accident (Also provide city, county, state) (if applicable) What was this employee doing when the accident occurred (loading truck, walking down stairs, etc.)? (if applicable)

Yes

No

How did this injury or occupational disease occur? Include time employee began work. Be specific and answer in detail. Use additional sheet if necessary.

Specify machine, tool, substance, or object most closely connected with the accident (if applicable) 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)

INJURY OR DISEASE

Nature of Injury or Occupational Disease (scratch, cut, bruise, strain, etc.)

Witness
Did employee return to next scheduled shift after accident? (if applicable)

Yes

No

Will you have light duty work available if necessary?

Yes
If validity of claim is doubted, state reason Treating physician/chiropractor name How many days per week does employee work? Location of Initial Treatment

No

Yes

No

Emergency Room From am pm To

Yes
am

No
pm

Hospitalized

Yes

No

Last day wages were earned

IMPORTANT

Scheduled days off

S

M

T

W

T

F

S

Rotating

Are you paying injured or disabled employee's wages during disability? Date of return to work

Yes

No

Date employee was hired

Last day of work after injury or disability

Number of work days lost

IMPORTANT LOST TIME INFO

Was the employee hired to work 40 hours per week?

Yes

No

If not, for how many hours a week 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, indicate the employee's gross earnings by pay period for 12 weeks prior 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.
Pay period ends on: SUN MON TUE WED THUR FRI SAT Emloyee is paid: WEEKLY BI-WKLY MONTHLY OTHER 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 Office of the Governor Consumer Health Assistance Toll Free: 1-888-333-1597 Web site: http://govcha.state.nv.us E-mail [email protected]
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

Insurer Use Only

Claim is:

Accepted

Denied

Deferred

3 Party Date Status Clerk Date

rd

Deemed Wage

Account No.

Class Code

Claims Examiner's Signature

Form C-3 (rev.11/05)

ORIGINAL ­ EMPLOYER

PAGE 2 ­ INSURER/TPA

PAGE 3 ­ EMPLOYEE