Get Nevada Fillable Form D 12a

The Nevada Fillable Form D 12a is a critical document used for requesting a hearing regarding contested claims. This guide provides clear, step-by-step instructions to assist users in completing the form online efficiently.

Follow the steps to fill out the Nevada Fillable Form D 12a online.

1. Click ‘Get Form’ button to obtain the form and open it in the appropriate editor.
2. Begin by filling out the employee information section. Enter the employee’s name, address, and telephone number. Ensure that the details are accurate and complete.
3. Next, provide the employer information. Fill in the employer’s name, address, and telephone number, followed by the claim number and the date of injury.
4. In the insurer information section, include the insurer’s name, address, and telephone number. Following this, input details for the third-party administrator, if applicable.
5. Clearly explain the basis for the appeal in the designated area. Use concise language to outline your disagreement with the insurer's determination.
6. Identify who is filing the request for a hearing by indicating whether it is filed by the injured employee or the employer. Include the date the form is filled out.
7. Sign the form to validate it. If applicable, also provide the signature of the advisor or representative.
8. Once all fields are completed, review the form for accuracy. After confirming that all information is correct, you can save the changes, download, print, or share the form as needed.

Get started now and complete your Nevada Fillable Form D 12a online today.