Workers' Compensation Forms and Worksheets

Workers' Compensation Forms and Worksheets

• C-Series Forms
  • C-1 Notice of Injury or Occupational Disease (Incident Report) (2/2020)
  • C-1 Fillable Form without Signature (2/2020)
  • C-1 Fillable Form with Signature (2/2020)
  • C-3 Employer's Report of Industrial Injury or Occupational Disease (2/2020)
  • C-3 Fillable Form (2/2020)
  • C-4 Employee's Claim for Compensation - Report of Initial Treatment - Fillable (8/23)
  • C-4A Release of Medical and Other Information For Nevada Workers’ Compensation Claims 8/21 - Discontinued eff 9/13/23
• D-Series Forms
  • D-1 Informational Poster (9/24)
  • D-2 Brief Description of Your Rights and Benefits if You Are Injured on the Job (9/24)
  • D-5 Wage Calculation Form for Claims Agent's Use (7/99)
  • D-6 Injured Employee's Request for Compensation (7/99)
  • D-7 Explanation of Wage Calculation (7/99)
  • D-8 Employer's Wage Verification Form (11/23)
  • D-9(a) Permanent Partial Disability Award Calculation Worksheet for Disability Up to and Including 30 Percent Body Basis
  • D-9(b) Permanent Partial Disability Award Calculation Worksheet for Disability Greater Than 30 Percent Body Basis (2/23)
  • D-9(c) Permanent Partial Disability Award Calculation Worksheet for Stress Claims Pursuant to NRS 616C.180 (6/10) - Eff through 10/6/24
  • D-9(c) Permanent Partial Disability Award Calculation Worksheet for Stress Claims Pursuant to NRS 616C.180 (10/24) - Eff 10/7/24
  • D-10(a) Election of Lump Sum Payment of Compensation for Disability Up to and Including 30 Percent (2/23)
  • D-10(b) Election of Lump Sum Payment of Compensation for Disability Greater Than 30 Percent (2/23)
  • D-11 Reaffirmation - Retraction of Lump Sum Request (8/21)
  • D-12(a) Request for Hearing - Contested Claim (10/18)
  • D-12(b) Request for Hearing - Uninsured Employer (2/08)
  • D-13 Injured Employee's Right to Reopen a Claim Which Has Been Closed (7/99)
  • D-14 Permanent Total Disability Report of Employment (7/99)
  • D-15 Election for Nevada Workers' Compensation Coverage for Out-of-State Injury (7/99)
  • D-16 Notice of Election for Compensation Benefits Under the Uninsured Employer Statutes (5/18)
  • D-17 Employee's Claim for Compensation - Uninsured Employer (9/24)
  • D-18 Assignment of Claim For Workers' Compensation - Uninsured Employer (2/04)
  • D-21 Fatality Report (9/24)
  • D-22 Notice to Employees - Tip Information (7/99)
  • D-23 Employee's Declaration of Election to Report Tips (7/99)
  • D-24 Request for Reimbursement of Expenses for Travel and lost Wages (6/06)
  • D-25 Affirmation of Compliance with Mandatory Industrial Insurance Requirements (11/23)
  • D-26 Application for Reimbursement of Claim-Related Travel Expenses (4/04)
  • D-27 Interest Calculation for Compensation (7/99)
  • D-28 Rehabilitation Lump Sum Request (7/99)
  • D-29 Lump Sum Rehabilitation Agreement (7/99)
  • D-30 Notice of Claim Acceptance (8/23)
  • D-31a Notice of Intention to Close Claim (10/24)
  • D-31b (10/24)
  • D-31c (10/24)
  • D-31d (10/24)
  • D-32 Authorization Request for Additional Chiropractic Treatment (7/99)
  • D-33 Authorization Request for Additional Physical Therapy Treatment (7/99)
  • D-34 Health Insurance Claim Form (CMS1500) via www.cms.gov
  • D-35 Request for Assignment of Rating Physician or Chiropractic Physician (10/24)
  • - Instructions for Completing a D-35 Form (10/24)
  • D-36 Request for Additional Medical Information and Medical Release (11/23)
  • D-37 Insurer's Subsequent Injury Checklist (12/03)
  • D-38 Injured Worker Index System Claims Registration Document – Eff 1/1/2019 Paper Form Not Accepted
  • D-39 Physician's and Chiropractic Physician's Progress Report - Certification of Disability (10/24)
  • D-43 Employee's Election to Reject Coverage and Election to Waive the Rejection of Coverage for Excluded Persons (2/04)
  • D-44 Election of Coverage by Employer; Employer Withdrawal of Election of Coverage (2/04)
  • D-45 Sole Proprietor Coverage (2/04)
  • D-46 Temporary Partial Disability Calculation Worksheet (7/99)
  • D-48 Proof of Coverage Notice (7/99)
  • D-49 Information Page (7/99)
  • D-50 Policy Termination, Cancellation and Reinstatement Notice (7/99)
  • D-53 Alternative Choice of Physician or Chiropractic Physician (10/24)
• OD Series
  • OD-1 Medical History Form (11/22)
  • OD-2 Lung Examination Form (11/22)
  • OD-3 Extensive Heart Examination Form (11/22)
  • OD-4 Limited Heart Examination Form (11/22)
  • OD-5 Hearing Examination Form (11/22)
  • OD-6 Sample Acknowledgment Letter (11/22)
  • OD-7 Physical Exam Information (11/22)
  • OD-8 Occupational Disease Claim Report (12/22)