Form online 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Employee Information. Fill in your name, address, and telephone number accurately.
3. Next, provide the Employer Information. Include the employer's name, address, and telephone number.
4. In the Claim No. and Date of Injury fields, input the relevant details pertaining to your claim.
5. Complete the Insurer Information section with the insurer’s name, address, and telephone number.
6. If applicable, fill out the Third-Party Administrator Information similarly.
7. Check the box if your request pertains to a specific claim filed under NRS 617.455 or 617.457.
8. Briefly explain the basis for your appeal in the designated area.
9. Indicate whether you are filing on behalf of yourself or as an employer by checking the appropriate box.
10. Finally, sign and date the form before submitting it through our platform.

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