Get NV Form C-3 2020-2024
If handwritten Reset Form please print. TO AVOID PENALTY THIS REPORT MUST BE COMPLETED AND MAILED TO THE INSURER WITHIN 6 WORKING DAYS OF RECEIPT OF THE C-4 FORM EMPLOYER S REPORT OF INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE Print Form EMPLOYER Employer s Name Nature of Business mfg etc. Office Mail Location. if different from mailing address City State Zip Code M. I. Last Name City THIRD PARTY ADMINISTRATOR State Zip Social Security Birthdate Sex Home Address Number and Street Telephone Number INSURER First Name Marital Status Single Male Female Was the employee paid for the day of injury Yes Is the injured employee a corporate officer. sole proprietor Corporate Officer Date of Injury if applicable Sole Proprietor Time of injury Hours Minute AM/PM if applicable Primary Language Spoken Divorced Married Widowed Department in which regularly employed Was employee in your employ when injured or disabled by occupational disease O/D No. partner Partner Date employer notified of injury or O/D Supervisor to whom injury or O/D reported Accident on employer s premises if applicable Address or location of accident Also provide city county state if applicable ACCIDENT OR DISEASE Age How long has this person been employed by you in Nevada Employee s occupation job title when hired or disabled In which state was employee hired Telephone OSHA Log Number FEIN What was this employee doing when the accident occurred loading truck walking down stairs etc* if applicable How did this injury or occupational disease occur Include time employee began work. Be specific and answer in detail* Use additional sheet if necessary. Specify machine tool substance or object most closely connected with the accident if applicable Witness Was more than one person injured in this accident if applicable If fatal give date of death Witness Part of body injured or affected INJURY OR DISEASE Nature of Injury or Occupational Disease scratch cut bruise strain etc* If validity of claim is doubted state reason. Location of Initial Treatment Treating physician/chiropractor name IMPORTANT Scheduled Days Off S M T W Emergency Room F Date employee was hired LOST TIME INFO Will you have light duty work available if necessary Did employee return to work next scheduled shift after accident if applicable How many days per week does employee work 40 hours per week Hospitalized From AM PM to PM Are you paying injured or disabled employee s wages during disability Rotating Last day of work after injury or disability If no for how many hours a week was the employee hired Date of return to work Number of work days lost Did the employee receive unemployment compensation any time during the last 12 months For the purpose of calculation of the average monthly wage indicate the employee s gross earning by pay period for 12 weeks prior to the date of injury or disability. If the injured employee is expected to be off work 5 days or more attach wage verification form D-8. Gross earnings will include overtime bonuses and other renumeration but will not include reimbursement for expenses.
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