Form C-3 "Employer's Report of Industrial Injury or Occupational Disease" - Nevada

What Is Form C-3?

This is a legal form that was released by the Nevada Department of Administration - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2010;
  • The latest edition provided by the Nevada Department of Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form C-3 by clicking the link below or browse more documents and templates provided by the Nevada Department of Administration.

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Download Form C-3 "Employer's Report of Industrial Injury or Occupational Disease" - Nevada

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Page background image
If handwritten,
Reset Form
TO AVOID PENALTY, THIS REPORT MUST BE
EMPLOYER'S REPORT OF INDUSTRIAL INJURY
please print.
COMPLETED AND MAILED TO THE INSURER WITHIN
OR OCCUPATIONAL DISEASE
Print Form
6 WORKING DAYS OF RECEIPT OF THE C-4 FORM
Nature of Business (mfg, etc.)
OSHA Log Number
Employer's Name
FEIN
Office Mail
Location . . if different from mailing address
Telephone Number
City, State, Zip Code
INSURER
THIRD PARTY ADMINISTRATOR
First Name
M.I.
Last Name
Social Security
Birthdate
Age
Primary Language Spoken
Home Address (Number and Street)
Sex
Marital Status
Male
Female
Single
Married
Divorced
Widowed
Was the employee paid for
City
State
Zip
How long has this person been employed by you
the day of injury?
Yes
No
in Nevada?
Employee's occupation (job title) when hired or disabled
In which state was employee hired?
Department in which regularly employed:
Telephone
Was employee in your employ when injured or disabled by
Is the injured employee a corporate officer? . . . sole proprietor?
. . . partner?
occupational disease (O/D)?
Corporate Officer
Sole Proprietor
Partner
Yes
No
Date of Injury
Date employer notified of injury or O/D
Supervisor to whom injury or O/D reported
(if applicable)
Time of injury (Hours; Minute AM/PM)
(if applicable)
Accident on employer's premises?
(if applicable)
Address or location of accident (Also provide city, county, state) (if applicable)
Yes
No
What was this employee doing when the accident occurred (loading truck, walking down stairs, etc.)? (if applicable)
How did this injury or occupational disease occur? Include time employee began work. Be specific and answer in detail. Use additional sheet if necessary.
Witness
Was more than one person
Specify machine, tool, substance, or object most closely connected with the accident (if applicable)
injured in this accident? (if
applicable
If fatal, give date of death Witness
Part of body injured or affected
Yes
No
Witness
Nature of Injury or Occupational Disease (scratch, cut, bruise, strain, etc.)
Will you have light duty work
Did employee return to work next scheduled
shift after accident? (if applicable)
available if necessary?
If validity of claim is doubted, state reason .
Yes
No
Yes
No
Location of Initial Treatment
Treating physician/chiropractor name
Emergency Room?
Hospitalized?
Yes
No
Yes
No
How many days per week does
Last day wages were earned
IMPORTANT
employee work?
PM to
From
AM
AM
PM
Scheduled Days Off
Are you paying injured or disabled employee's wages during disability
?
S
M
T
W
T
F
S
Rotating
No
Yes
Date employee was hired
Last day of work after injury or disability
Date of return to work
Number of work days lost
Was the employee hired to work
If no, for how many hours a
Did the employee receive unemployment compensation any time during the last
40 hours per week?
Yes
No
week was the employee hired?
12 months?
Yes
No
For the purpose of calculation of the average monthly wage, indicate the employee's gross earning 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 renumeration, 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 hireto the date of injury or disability.
Pay Period ends on:
Employee
On the date of injury or disability
Week
Weekly
Monthly
Other
Hour
per
the employee's wage was:
is paid:
S
M
T
W
T
F
S
BiWeekly
Bi-Monthly
Month
Day
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 cha@govcha.state.nv.us
I affirm that the information provided above regarding the accident and injury or occupational disease is correct to
Employer's Signature and Title
Date
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.
Deemed Wage
Account No.
Class Code
Claim is:
Accepted
Denied
Deferred
Third-Party
Claims Examiner's Signature
Date
Status Clerk
Date
Form C-3 (rev.05/10)
If handwritten,
Reset Form
TO AVOID PENALTY, THIS REPORT MUST BE
EMPLOYER'S REPORT OF INDUSTRIAL INJURY
please print.
COMPLETED AND MAILED TO THE INSURER WITHIN
OR OCCUPATIONAL DISEASE
Print Form
6 WORKING DAYS OF RECEIPT OF THE C-4 FORM
Nature of Business (mfg, etc.)
OSHA Log Number
Employer's Name
FEIN
Office Mail
Location . . if different from mailing address
Telephone Number
City, State, Zip Code
INSURER
THIRD PARTY ADMINISTRATOR
First Name
M.I.
Last Name
Social Security
Birthdate
Age
Primary Language Spoken
Home Address (Number and Street)
Sex
Marital Status
Male
Female
Single
Married
Divorced
Widowed
Was the employee paid for
City
State
Zip
How long has this person been employed by you
the day of injury?
Yes
No
in Nevada?
Employee's occupation (job title) when hired or disabled
In which state was employee hired?
Department in which regularly employed:
Telephone
Was employee in your employ when injured or disabled by
Is the injured employee a corporate officer? . . . sole proprietor?
. . . partner?
occupational disease (O/D)?
Corporate Officer
Sole Proprietor
Partner
Yes
No
Date of Injury
Date employer notified of injury or O/D
Supervisor to whom injury or O/D reported
(if applicable)
Time of injury (Hours; Minute AM/PM)
(if applicable)
Accident on employer's premises?
(if applicable)
Address or location of accident (Also provide city, county, state) (if applicable)
Yes
No
What was this employee doing when the accident occurred (loading truck, walking down stairs, etc.)? (if applicable)
How did this injury or occupational disease occur? Include time employee began work. Be specific and answer in detail. Use additional sheet if necessary.
Witness
Was more than one person
Specify machine, tool, substance, or object most closely connected with the accident (if applicable)
injured in this accident? (if
applicable
If fatal, give date of death Witness
Part of body injured or affected
Yes
No
Witness
Nature of Injury or Occupational Disease (scratch, cut, bruise, strain, etc.)
Will you have light duty work
Did employee return to work next scheduled
shift after accident? (if applicable)
available if necessary?
If validity of claim is doubted, state reason .
Yes
No
Yes
No
Location of Initial Treatment
Treating physician/chiropractor name
Emergency Room?
Hospitalized?
Yes
No
Yes
No
How many days per week does
Last day wages were earned
IMPORTANT
employee work?
PM to
From
AM
AM
PM
Scheduled Days Off
Are you paying injured or disabled employee's wages during disability
?
S
M
T
W
T
F
S
Rotating
No
Yes
Date employee was hired
Last day of work after injury or disability
Date of return to work
Number of work days lost
Was the employee hired to work
If no, for how many hours a
Did the employee receive unemployment compensation any time during the last
40 hours per week?
Yes
No
week was the employee hired?
12 months?
Yes
No
For the purpose of calculation of the average monthly wage, indicate the employee's gross earning 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 renumeration, 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 hireto the date of injury or disability.
Pay Period ends on:
Employee
On the date of injury or disability
Week
Weekly
Monthly
Other
Hour
per
the employee's wage was:
is paid:
S
M
T
W
T
F
S
BiWeekly
Bi-Monthly
Month
Day
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 cha@govcha.state.nv.us
I affirm that the information provided above regarding the accident and injury or occupational disease is correct to
Employer's Signature and Title
Date
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.
Deemed Wage
Account No.
Class Code
Claim is:
Accepted
Denied
Deferred
Third-Party
Claims Examiner's Signature
Date
Status Clerk
Date
Form C-3 (rev.05/10)