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Workers' Compensation Forms

The following links will assist you with filing Worker's Compensation forms.

Workers Compensation Supervisor Forms

Procedures

  • Procedure Flowchart
  • Supervisor Checklist
  • Supervisor Workers' Comp Statutory Timelines
  • Early Return to Work Policy
  • Workers Comp SAM 0524.0

Forms

  • C-3 Fillable Form - Employer's Report of Industrial Injury or Occupational Disease
  • C-3 Form - Employer's Report of Industrial Injury or Occupational Disease
  • D-8 - Form - Employer's Wage Verification Form
  • Offer Of Modified Duty Form
  • Supervisor's Accident Investigation Form
  • Physical Characteristics Form

Forms To Provide and Review With Injured Employees

  • C-1 Fillable Form - Notice Of Injury Form
  • C-1 Form - Notice Of Injury Form
  • Employee Responsibility Form
  • Leave Choice Option Form
  • Physical Assessment Form

Workers Compensation Employee Forms

Links

  • Employee Workers' Comp Statutory Timelines
  • Pharmacies

Forms

  • C-1 Fillable Form - Notice of Injury Form
  • C-1 Form - Notice of Injury
  • Description Of Employee Rights (D-2 Form)
  • Employee Responsibility Form/Info
  • Leave Choice Form
  • Physical Assessment Form
  • Application for Reimbursement of Claim Related Travel Expenses Form (D-26)

Volunteers


2023

  • Volunteer Insurance Coverage Change for Work Comp
  • Reporting Procedures
  • Volunteer & Board Member Application
  • Volunteer, Inmate, Intern & Board Member Job Description
  • Volunteer Memo of Understanding
  • Volunteer Calculator 2023 (Jan 2023- Dec 2023)

Contact

201 S. Roop Street, Suite 201
Carson City, NV 89701
Phone: (775) 687-1750
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