Insurance and Claims Forms

Notice Of Injury Or Occupational Disease (Form C1)

Completed by the injured employee or supervisor for all accidents and injuries. Please fax the C1 form as soon as possible to 702-895-5227. Must be submitted within seven days from the date of accident/injury.

Form C1

Information For Employee (Form D2)

This form provides basic information on rights and benefits relating to workers' compensation pursuant to NRS 616C.050.

Form D2

Claim For Compensation/Report Of Initial Treatment (Form C4)

This form starts the claim process and can only be obtained from the medical provider when you go for medical treatment. Be sure to inform the medical provider that you were injured at work. The medical provider will give you a copy of this form and will forward a copy to the workers' compensation office and/or the third party administrator.

The employee has 90 days from the date of the injury to seek medical treatment. The completed C4 form must be received by the third party administrator within 90 days from the date of injury.

If you seek medical attention from a medical provider other than the approved clinics, be sure to check with the workers' compensation office to ensure that this form has been received. Your claim cannot be processed without this form.

Supervisor's Injury/Illness/Incident Report

The supervisor should reach out to Risk Management and Safety to acquire the "Supervisor's Injury/Illness/Incident Report form" immediately after being notified of any work-related accident or incident (injury, illness, vehicle accident, property damage or near-miss incident) and forwards it to the appropriate Occupational Safety Office.