Occupational Disease Claim Report - Nevada 2026

1. Click ‘Get Form’ to open the Occupational Disease Claim Report in the editor.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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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