Nev. Admin. Code § 616C.274 - Form for requesting hearing before hearing officer or for notice of appeal; information required to be provided by insurer or third-party administrator
1. A request for a hearing before a hearing officer or a notice of appeal filed with the Hearings Division must be filed:
(a) On a form provided by an insurer, an organization for managed care or the Hearings Division; or
(b) On a similar form approved by the Department of Administration.
2. An insurer or the third-party administrator for an insurer shall provide the following information on each form used to request a hearing:
(a) The name and last known mailing address of the claimant;
(b) The name under which the employer was doing business at the time of the injury and the last known mailing address and telephone number of the employer;
(c) If the insurer is a self-insured employer:
(1) The name, address and telephone number of the self-insured employer; and
(2) The name, address and telephone number of the third-party administrator of the self-insured employer, if any;
(d) The number of the claim; and
(e) The date of injury or, in the case of occupational disease, the estimated or approximate date of injury.
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