Free D-12(a) - Nevada

REQUEST FOR HEARING - CONTESTED CLAIM
(Pursuant to NAC 616C.274) REPLY TO: Department of Administration Hearings Division 1050 E. William Street, Ste. 400 Carson City, NV 89701 (775) 687-8440 OR Department of Administration Hearings Division 2200 S. Rancho Drive, Suite 210 Las Vegas, NV 89102 (702) 486-2525

Employee Information
Employee's Name and Address

Employer Information
Employer's Name and Address

Employee's Telephone Number

Claim No. Date of Injury

Employer's Telephone Number

Insurer Information
Insurer's Name and Address

Third-Party Administrator Information
Third-Party Administrator's Name and Address

Insurer's Telephone Number

Third-Party Administrator's Telephone Number

Do Not Complete or Mail This Form Unless You Disagree With the Insurer's Determination.
YOU MUST INCLUDE A COPY OF THE DETERMINATION LETTER OR A HEARING WILL NOT BE SCHEDULED PURSUANT TO NRS 616C.315. 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-12a (Rev. 12/07)