Get Nv D-12a 2018-2026

The NV D-12a is an essential form for individuals seeking a hearing regarding a contested claim. This guide provides clear, step-by-step instructions to assist users in completing the form online efficiently and accurately.

Follow the steps to complete the NV D-12a form online.

1. Press the ‘Get Form’ button to access the NV D-12a and open it in the editing interface.
2. Begin by filling in the employee information. Provide the employee’s name, address, and telephone number accurately to ensure proper identification.
3. Next, enter the employer information. This includes the employer’s name, address, and telephone number. Ensure that this information corresponds to the employee's records.
4. Fill in the claim number and date of injury where prompted. This information is critical for the claims process and should be taken from previously provided documents.
5. Proceed to the insurer information section. Input the insurer’s name, address, and telephone number. This should reflect the details provided in the claim process.
6. Include the third-party administrator's information if applicable. Enter their name, address, and telephone number accurately.
7. In the relevant section, check the box if your request pertains to a claim filed under NRS 617.455 or 617.457.
8. Attach a copy of the determination letter. This is mandatory for your hearing to be scheduled as per NRS 616C.315.
9. Briefly explain the basis for your appeal in the designated area, providing clear and concise information.
10. Indicate whether the request for hearing is filed by the injured employee or the employer by checking the appropriate box.
11. Date the form clearly, entering the date of submission and ensuring it is up to date.
12. Finally, provide the signature of the injured employee or employer, as well as the signature of their representative, if applicable.
13. Once completed, save your changes, and download, print, or share the form as needed.

Start filling out the NV D-12a online now to ensure your hearing request is processed promptly.