Free , Occupational Disease Claim Report - Nevada

State of Nevada Department of Business and Industry Division of Industrial Relations

OCCUPATIONAL DISEASE CLAIM REPORT (NRS 617.357)
Please check one only: INITIAL REPORT UPDATE REPORT

ALL REPORTS (Complete this section for INITIAL REPORTS AND UPDATES)
Date Report Submitted (to WCS): Insurer Name: Insurer Certificate Number: Employer Name: Claim Number: Submitted by: Company: Address: City, State, Zip: Telephone E-mail Address

Insurer FEIN:

Individual Name and Title (please print) Insurer TPA Other

INITIAL & UPDATE REPORTS (Report within 30 days of acceptance/denial or any changes to the claim)
Date Claim (C-4) Received: Claim Disposition: Accepted Reason for Acceptance/Denial: Estimated Medical Costs of Claim: $ Description of Nature of Claim: NATURE OF CLAIM CODE (Select from the IAIABC Codes below): 61 ASBESTOSIS, LUNG DISEASE FROM INHALED ASBESTOS 62 BLACK LUNG, CHRONIC LUNG DISEASE/COAL 63 BYSSINOSIS, PNEUMOCONIOSIS FROM COTTON, FLAX 64 SILICOSIS, PNEUMOCONIOSIS FROM INHALED SILICA 65 RESPIRATORY DISORDERS, GASSES, FUMES,
CHEMICALS, ETC.

Denied

Date of Injury: Date Accepted/Denied: Statute/Reg. Citation:

60 DUST DISEASE, ALL OTHER PNEUMOCONIOSIS Symptoms/Exposure Only:
(No Confirmed Diagnosis)

73 CONTAGIOUS DISEASE, UNSPECIFIED 74 CANCER 75 AIDS 79 HEPATITIS C 03 ANGINA PECTORIS, CHEST PAIN 41 MYOCARDIAL INFARCTION, HEART DISEASE/CONDITIONS 00 OTHER BE SPECIFIC YES NO

UPDATE REPORTS ONLY (Report within 30 days of appeal, closure, reopening, or confirmed diagnosis)
Appeal(s) of Acceptance/Denial: Date Appeal Filed: Appeal 1st 2nd 3rd Decision: Affirmed

Other Hearing Date: Modified Reversed Remanded Decision Date:

Diagnosis Confirmed: YES NO Did Nature of Claim Change? YES - NEW CODE # NO Additional Information/Explanation (include clarification of activity reported):

Initial Claim Closure Date: Date Claim Reopened (if applicable): Subsequent Claim Closure Date (if applicable): OD-8 6/06