Workers' Compensation Forms and Worksheets. C-Series Forms. C-1 Notice of Injury or Occupational Disease (Incident Report) (2/2020) C-3 Employer's Report of Industrial Injury or Occupational Disease (2/2025) C-4 Employee's Claim for Compensation - Report of Initial Treatment - Fillable (2/2025)

form c-4 please type or print ... and correct to the best of my knowledge and that i have provided this information in order to obtain the benefits of nevada’s industrial insurance and occupational diseases acts (nrs 616a to 616d, inclusive, or chapter 617 of nrs). i hereby authorize any physician, chiropractor, surgeon,

In Nevada, a workers' compensation claim begins when a C-4 form is sent to the insurance company that your employer uses for workers' compensation coverage. You will need to fill out your part of the C-4 form the first time you visit a medical provider for treatment of …

C-1 "NOTICE OF INJURY OR OCCUPATIONAL DISEASE (Incident Report)" form. Notice of Injury or Occupational Disease [C-1 form]

Filing a C-4 form starts a claim. The C-4 form is filled out when you first get medical treatment for your work injury. Medical providers in Nevada are supposed to have C-4 forms available for injured workers.

Form C-4 Submission •Within 3 working days, complete and file Form C-4 with employer and CORRECT insurer •Must be on form prescribed by Division of Industrial Relations (DIR) –C-4s are available on the WCS website: dir.nv.gov/WCS/Home/ •Maintain sufficient supply of appropriate forms •Fines for untimely or incomplete form

Form C-4 Employee’s Claim for Compensation/Report of Initial Treatment. This form should be submitted at the same time as Form C-1. A copy of the form must be provided to EMPLOYERS and to your injured worker and you must also keep a copy of this form for your records.

Claim for Compensation (Form C-4): If medical treatment is sought, the form C-4 is available at the place of initial treatment. A completed "Claim for Compensation" (Form C-4) must be filed within 90 days after an accident or OD.

2021年10月21日 · When an employee has suffered an industrial injury in Nevada, one step the injured worker must take is to file their worker’s compensation claim by filling out a C-4 form. The C-4 form will be filled out by the injured worker at their initial doctor/hospital visit.