TO AVOID PENALTY, THIS REPORT MUST BE COMPLETED AND MAILED TO THE INSURER WITHIN 6 WORKING DAYS OF RECEIPT OF THE C-4 FORM
Please Type or Print
Nature of Business (mfg., etc.)
EMPLOYER'S REPORT OF INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE
FEIN OSHA Log # Telephone THIRD-PARTY ADMINISTRATOR Birthdate Age Primary Language Spoken
EMPLOYER
Employer's Name Office Mail Address City First Name M.I. State Zip Last Name
Location . . . If different from mailing address INSURER Social Security
EMPLOYEE
Home Address (Number and Street) Sex City State Zip Male Female Marital Status Single Married Divorced Widowed
Was the employee paid for the day of injury?
(If applicable)
Yes
No
How long has this person been employed by you in Nevada? Department in which regularly employed: Was employee in your employ when injured or disabled Yes No by occupational disease (O/D)? Supervisor to whom injury or O/D reported Accident on employer's premises? (if applicable)
In which state was employee hired? Telephone
Employee's occupation (job title) when hired or disabled
. . . sole proprietor? Yes
(if applicable)
Is the injured employee a corporate officer? Yes No
. . . partner? Yes No
No
Date of Injury (if applicable) Time of injury (Hours; Minute AM/PM)
Date employer notified of injury or O/D
ACCIDENT OR DISEASE
Address or location of accident (Also provide city, county, state) (if applicable) What was this employee doing when the accident occurred (loading truck, walking down stairs, etc.)? (if applicable)
Yes
No
How did this injury or occupational disease occur? Include time employee began work. Be specific and answer in detail. Use additional sheet if necessary.
Specify machine, tool, substance, or object most closely connected with the accident (if applicable) Part of body injured or affected If fatal, give date of death
Witness Witness
Was there more than one person injured in this accident? (if applicable)
INJURY OR DISEASE
Nature of Injury or Occupational Disease (scratch, cut, bruise, strain, etc.)
Witness
Did employee return to next scheduled shift after accident? (if applicable)
Yes
No
Will you have light duty work available if necessary?
Yes
If validity of claim is doubted, state reason Treating physician/chiropractor name How many days per week does employee work? Location of Initial Treatment
No
Yes
No
Emergency Room From am pm To
Yes
am
No
pm
Hospitalized
Yes
No
Last day wages were earned
IMPORTANT
Scheduled days off
S
M
T
W
T
F
S
Rotating
Are you paying injured or disabled employee's wages during disability? Date of return to work
Yes
No
Date employee was hired
Last day of work after injury or disability
Number of work days lost
IMPORTANT LOST TIME INFO
Was the employee hired to work 40 hours per week?
Yes
No
If not, for how many hours a week was the employee hired?
Did the employee receive unemployment compensation any time during the last 12 months? Yes No Do not know
For the purpose of calculation of the average monthly wage, indicate the employee's gross earnings by pay period for 12 weeks prior to the date of injury or disability. If the injured employee is expected to be off work 5 days or more, attach wage verification form (D-8). Gross earnings will include overtime, bonuses, and other remuneration, but will not include reimbursement for expenses. If the employee was employed by you for less than 12 weeks, provide gross earnings from the date of hire to the date of injury or disability.
Pay period ends on: SUN MON TUE WED THUR FRI SAT Emloyee is paid: WEEKLY BI-WKLY MONTHLY OTHER SEMI-MONTHLY
On the date of injury or disability the employee's wage was: $
per
Hr
Day
Wk
Mo
For assistance with Workers' Compensation Issues you may contact the Office of the Governor Consumer Health Assistance Toll Free: 1-888-333-1597 Web site: http://govcha.state.nv.us E-mail [email protected]
I affirm that the information provided above regarding the accident and injury or occupational disease is correct to the best of my knowledge. I further affirm the wage information provided is true and correct as taken from the payroll records of the employee in question. I also understand that providing false information is a violation of Nevada law.
Employer's Signature and Title
Date
Insurer Use Only
Claim is:
Accepted
Denied
Deferred
3 Party Date Status Clerk Date
rd
Deemed Wage
Account No.
Class Code
Claims Examiner's Signature
Form C-3 (rev.11/05)
ORIGINAL EMPLOYER
PAGE 2 INSURER/TPA
PAGE 3 EMPLOYEE