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Occupational Disease Claim Report - Nevada

Occupational Disease Claim Report - Nevada 2026

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The document is an Occupational Disease Claim Report from the State of Nevada's Department of Business and Industry, Division of Industrial Relations. It outlines the procedures for submitting claims related to occupational diseases, including required information for both initial claims and appeals. The report specifies timelines for submission, details on claim acceptance or denial, and categorizes various types of occupational diseases covered under Nevada law.

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Click ‘Get Form’ to open the Occupational Disease Claim Report in the editor.
Begin by filling out Part 1. Enter the Insurer Name, FEIN, Certificate Number, and Claim Number. Ensure accuracy as this information is crucial for processing your claim.
Provide details about the Claimant’s Employer and who is submitting the form. Include their Company name, Address, City, State, Zip code, and contact information.
Indicate the Date of Injury and when the Claim (C-4) was received by the Insurer/TPA. Select the Claim Disposition status: Accepted or Denied, and provide relevant dates.
If denied, choose a reason from the provided options that best describes your situation. Fill in Estimated Medical Costs of Claim and a brief Description of Claim.
In Part 2, if applicable, complete details regarding any appeals including who appealed, dates filed, hearing dates, decisions made, and confirmation of diagnosis.

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What is a C1 form in Nevada?

NOTICE OF INJURY OR OCCUPATIONAL DISEASE (Incident Report)

What is a C3 form in Nevada?

EMPLOYERS REPORT OF INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE.

What is a C4 form in Nevada?

You must seek medical treatment and complete the Claim for Compensation/Physicians Report of Initial Injury, Form C-4, within 90 days from the date of injury. The C-4 form is the legal document for filing a claim in Nevada.

What is an occupational disease claim?

An occupational disease (OD) is defined as a wound or other. condition of the body caused by a specific event or series of. events or incidents occurring: a) During one work day or work shift. b) Over more than one work day or work shift.

What is a Nevada C1 form?

Notice of Injury or Occupational Disease (Incident Report Form C-1): If an injury or occupational disease (OD) arises out of and in the course of employment, you must provide written notice to your employer as soon as practicable, but no later than 7 days after the accident or OD.

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