Free D-17 - Nevada

EMPLOYEE'S CLAIM FOR COMPENSATION - UNINSURED EMPLOYER
DIVISION OF INDUSTRIAL RELATIONS ­ WORKERS' COMPENSATION SECTION 400 W. KING STREET, SUITE 400 OR 1301 N. GREEN VALLEY PARKWAY, SUITE 200 Claim Number CARSON CITY NEVADA 89703 HENDERSON, NV 89074 EMPLOYEE First Name M.I. Last Name Soc. Sec. No. Birth Date Home Address (Number and Street) Mailing Address Sex: Male [ ] Female [ ] Date Hired Marital Status: City State Zip Name of Immediate Supervisor Union Affiliation Telephone Mail to:

Occupation (Job Title)

No. of Dependents

Single [ ] Married [ ] Divorced [ ] Widow/er[ ] Where Were You Hired?

How Many Persons Are Employed In This Business? Names of Other Employees (Use Additional Sheets if Necessary) 1. 2. 3. EMPLOYER Owner's Name First M.I. City Last Name State Zip City State Zip Telephone Soc. Sec. No. Telephone

Owner's Address Number and Street Name of Business

Business Address (Number and Street)

Nature of Business (Manufacturing, Etc.) ACCIDENT/OCCUPATIONAL DISEASE Date of Injury or Date You Hour of Injury (if applicable) Learned of Disability and Its A.M. [ ] P.M. [ ] Relationship to Your Employment Address Where The Accident Occurred (if applicable)

Date Employer Notified of Injury/Occupational Disease

What Were You Doing When Accident Occurred? (Loading Truck, Walking Down Stairs, Etc.) (if applicable) How Did Accident or Occupational Disease Occur? (Be Specific and in Detail; Use Additional Sheets if Necessary) Specify Machine, Tool, Substance, Condition or Object Most Closely Connected With Accident or Occupational Disease Nature of Injury or Occupational Disease (Scratch, Cut, Bruise, Etc.) Part(s) of Body Injured (if applicable) Side Injured (if applicable) To Whom Was Injury or Occupational Disease Reported?

Right [ ] Left [ ] Both [ ] Were There Witnesses to Accident? (Give Names) (if applicable) Last Paid On Wage $ per Last Day Worked How Are You Paid? Cash [ ] Check [ ]

Did You Return to Next Scheduled Date Returned To Work What Are Your Normal Work Days? Shift After Accident? Yes [ ] No [ ] Doctor's Address TREATMENT Doctor Who Treated You for This Injury or Occupational Disease Date of Visit Name of Hospital How Were You Transported From the Place of Accident to the Place of Treatment (Car, Ambulance, Etc.)? Hour of Visit A.M. [ ] P.M. [ ] Address of Hospital (if applicable) Who Provided This Transportation? Were You Hospitalized? Yes [ ] No [ ]

I declare under penalty of perjury that the answers above are true and correct to the best of my knowledge. Date Signature

I hereby elect to receive compensation under the provisions of chapters 616A to 616D, inclusive or chapter 617 of the Nevada Revised Statutes (NRS), and do by separate assignment, make an irrevocable assignment of subrogation pursuant to NRS 616C.215 to the Division of Industrial Relations. Date Signature D-17 (rev.02/04)