Free D-12(b) - Nevada


File Size: 34.9 kB
Pages: 1
Date: February 28, 2008
File Format: PDF
State: Nevada
Category: Workers Compensation
Author: jdenison
Word Count: 191 Words, 1,297 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dirweb.state.nv.us/FORMS/d-12b.pdf

Download D-12(b) ( 34.9 kB)


Preview D-12(b)
REQUEST FOR HEARING - UNINSURED EMPLOYER
REPLY TO: Department of Administration Hearings Division - Appeals Officer 1050 E. William Street, Ste. 450 Carson City, NV 89701 (775) 687-8420 OR Department of Administration Hearings Division - Appeals Officer 2200 S. Rancho Drive, Suite 220 Las Vegas, NV 89102 (702) 486-2525

Injured Employee's Name (Last, First, M.I.) Claim No. Address (P.O. Box/Apt./Street) City/State/Zip Code Employer's Name Address City/State/Zip Code Telephone No. Date of Injury Account No. Employer's Phone No. Employer's Representative

I hereby request a hearing before the Appeals Officer to review the determination made by the Administrator of the Division of Industrial Relations regarding Employer/Employee relationship in the designated claim above. The determination relates to (please mark appropriate space): Assignment of claim to the Uninsured Employers' Claim Account Non-assignment of claim to Uninsured Employers' Claim Account 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-12b (Rev. 02/08)