Free - Nevada

TO:

RE: Claim No: Employer: Insurer: TPA: Date of Injury: Date of Notice: Body Part: NOTICE OF CLAIM ACCEPTANCE (Pursuant to NRS 616C.065)

Dear The above referenced claim has been accepted on your behalf by (Insert Insurer Name). Please check the information contained on this notice. If you find any of the information to be incorrect, please notify the insurer handling the claim. If you disagree with the above determination, you do have the right to appeal by requesting a hearing before a Hearing Officer by completing the bottom portion of this notice and sending it to the State of Nevada, Department of Administration, Hearings Division. Your appeal must be filed within seventy (70) days after the date on which the notice of this determination was mailed. Department of Administration Hearings Division 1050 E. William Street, Ste. 400 Carson City, NV 89710 (775) 687-5966 OR Department of Administration Hearings Division 2200 S. Rancho Drive, Suite 210 Las Vegas, NV 89102 (702) 486-2525

Very truly yours, Reason for appeal:

Signature Retain a copy for your records c.: Enclosure

Date

D-30 (rev. 04/07)