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 Business and Industry - 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 February 1, 2020;
  • The latest edition provided by the Nevada Department of Business and Industry;
  • 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 Business and Industry.

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

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TO AVOID PENALTY, THIS REPORT MUST BE
EMPLOYER’S REPORT OF INDUSTRIAL INJURY
Please
COMPLETED AND MAILED TO THE INSURER WITHIN
Type or Print
OR OCCUPATIONAL DISEASE
6 WORKING DAYS OF RECEIPT OF THE C-4 FORM
Nature of Business (mfg., etc.)
FEIN
OSHA Log #
Employer’s Name
Office Mail Address
Location . . . If different from mailing address
Telephone
City
State
Zip
INSURER
THIRD-PARTY ADMINISTRATOR
First Name
M.I.
Last Name
Social Security
Birthdate
Age
Primary Language Spoken
Home Address (Number and Street)
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
City
State
Zip
Was the employee paid for the day of injury?
How long has this person been employed by you
in Nevada?
Yes
No
(If applicable)
In which state was employee hired?
Employee’s occupation (job title) when hired or disabled
Department in which regularly employed:
Telephone
Is the injured employee a corporate officer?
. . .
sole proprietor?
. . .
partner?
Was employee in your employ when injured or disabled
by occupational disease (O/D)?
Yes
No
Yes
No
Yes
No
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)
Address or location of accident (Also provide city, county, state) (if applicable)
Accident on employer’s premises?
(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 there more than one
Specify machine, tool, substance, or object most closely connected with the accident
person injured in this
(if applicable)
accident? (if applicable)
Part of body injured or affected
If fatal, give date of death
Witness
Yes
No
Nature of Injury or Occupational Disease (scratch, cut, bruise, strain, etc.)
Witness
Did employee return to next scheduled shift after
Will you have light duty work
accident? (if applicable)
available if necessary?
Yes
No
Yes
No
If validity of claim is doubted, state reason
Location of Initial Treatment
Treating physician/chiropractor name
Yes
No
Yes
No
Emergency Room
Hospitalized
How many days per week does
Last day wages were earned
IMPORTANT
am
employee work?
From
am
pm
To
pm
Scheduled
S
M
T
W
T
F
S
Rotating
Are you paying injured or disabled employee’s wages during disability
?
Yes
No
days off
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
If not, for how many hours a week
Did the employee receive unemployment compensation any time during the last
work 40 hours per week?
Yes
No
was the employee hired?
Yes
No
Do not know
12 months?
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.
SAT
On the date of injury or disability
Pay period
SUN
TUE
THUR
Emloyee
WEEKLY
MONTHLY
OTHER
per Hr
Day
Wk
Μο
MON
FRI
SEMI-MONTHLY
ends on:
WED
the employee’s wage was:
$
is paid:
BI-WKLY
For assistance with Workers’ Compensation Issues you may contact the State of Nevada Office for Consumer
Health Assistance Toll Free: 1-888-333-1597 Web site:
http://dhhs.nv.gov/Programs/CHA/
E-mail: cha@govcha.nv.gov
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
rd
Claim is:
Accepted
Denied
Deferred
3
Party
Claims Examiner’s Signature
Date
Status Clerk
Date
ORIGINAL – EMPLOYER
PAGE 2 – INSURER/TPA
PAGE 3 – EMPLOYEE
Form C-3 (rev.02/20)
TO AVOID PENALTY, THIS REPORT MUST BE
EMPLOYER’S REPORT OF INDUSTRIAL INJURY
Please
COMPLETED AND MAILED TO THE INSURER WITHIN
Type or Print
OR OCCUPATIONAL DISEASE
6 WORKING DAYS OF RECEIPT OF THE C-4 FORM
Nature of Business (mfg., etc.)
FEIN
OSHA Log #
Employer’s Name
Office Mail Address
Location . . . If different from mailing address
Telephone
City
State
Zip
INSURER
THIRD-PARTY ADMINISTRATOR
First Name
M.I.
Last Name
Social Security
Birthdate
Age
Primary Language Spoken
Home Address (Number and Street)
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
City
State
Zip
Was the employee paid for the day of injury?
How long has this person been employed by you
in Nevada?
Yes
No
(If applicable)
In which state was employee hired?
Employee’s occupation (job title) when hired or disabled
Department in which regularly employed:
Telephone
Is the injured employee a corporate officer?
. . .
sole proprietor?
. . .
partner?
Was employee in your employ when injured or disabled
by occupational disease (O/D)?
Yes
No
Yes
No
Yes
No
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)
Address or location of accident (Also provide city, county, state) (if applicable)
Accident on employer’s premises?
(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 there more than one
Specify machine, tool, substance, or object most closely connected with the accident
person injured in this
(if applicable)
accident? (if applicable)
Part of body injured or affected
If fatal, give date of death
Witness
Yes
No
Nature of Injury or Occupational Disease (scratch, cut, bruise, strain, etc.)
Witness
Did employee return to next scheduled shift after
Will you have light duty work
accident? (if applicable)
available if necessary?
Yes
No
Yes
No
If validity of claim is doubted, state reason
Location of Initial Treatment
Treating physician/chiropractor name
Yes
No
Yes
No
Emergency Room
Hospitalized
How many days per week does
Last day wages were earned
IMPORTANT
am
employee work?
From
am
pm
To
pm
Scheduled
S
M
T
W
T
F
S
Rotating
Are you paying injured or disabled employee’s wages during disability
?
Yes
No
days off
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
If not, for how many hours a week
Did the employee receive unemployment compensation any time during the last
work 40 hours per week?
Yes
No
was the employee hired?
Yes
No
Do not know
12 months?
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.
SAT
On the date of injury or disability
Pay period
SUN
TUE
THUR
Emloyee
WEEKLY
MONTHLY
OTHER
per Hr
Day
Wk
Μο
MON
FRI
SEMI-MONTHLY
ends on:
WED
the employee’s wage was:
$
is paid:
BI-WKLY
For assistance with Workers’ Compensation Issues you may contact the State of Nevada Office for Consumer
Health Assistance Toll Free: 1-888-333-1597 Web site:
http://dhhs.nv.gov/Programs/CHA/
E-mail: cha@govcha.nv.gov
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
rd
Claim is:
Accepted
Denied
Deferred
3
Party
Claims Examiner’s Signature
Date
Status Clerk
Date
ORIGINAL – EMPLOYER
PAGE 2 – INSURER/TPA
PAGE 3 – EMPLOYEE
Form C-3 (rev.02/20)