Free D-45 - Nevada

SOLE PROPRIETOR COVERAGE
Pursuant to NRS 616B.659

Sole Proprietor Name: Business Name: Business Address: Telephone Number: Federal Identification Number:

NOTICE OF ELECTION OF COVERAGE

Sole Proprietor Signature: Effective Date:

NOTICE OF WITHDRAWAL OF ELECTED COVERAGE

Sole Proprietor Signature: Effective Date:

NOTICE TO PAY ADDITIONAL PREMIUMS FOR ADDITIONAL COVERAGE

Sole Proprietor Signature: Effective Date: Date Notice to Administrator: Date Notice to System: Date Notice to Insurer:

FOR WCS USE ONLY Method of Transmission Electronic Transmission/Fax [

First Class Mail [ Date Notice Received:

]

]

Personally Served [ ]

D-45 (Rev. 02/04)