Workers’ Compensation Forms

Notice of Injury or Occupational Disease (C1)

Completed by the injured employee or supervisor for all accidents and injuries. Please fax the C1 form as soon as possible to 895-5227. Must be submitted within 7 days from the date of accident/injury.

c-1.pdf

D2 – Information for Employee

d-2.pdf

Claim for Compensation/Report of Initial Treatment (C4)

This form starts the claim process and can only be obtained from the medical provider when you go for medical treatment. Be sure to inform the medical provider that you were injured at work. The medical provider will give you a copy of this form and will forward a copy to the Workers' Compensation Office and/or the Third Party Administrator.

The employee has 90 days from the date of the injury to seek medical treatment. The completed C4 form must be received by the Third Party Administrator with 90 days from the date of injury.

If you seek medical attention from a medical provider other than the approved clinics, be sure to check with the Workers' Compensation Office to ensure that this form has been received. Your claim cannot be processed without this form.

Supervisor's Injury/Illness/Incident Report

The supervisor completes this form immediately after being notified of any work-related accident or incident (injury, illness,vehicle accident, property damage or near-miss incident) and forwards it to the appropriate Occupational Safety Office within two (2) working days:

UNLV and Nevada State College: Occupational Safety Office, Mailstop 1042
College of Southern Nevada: Environmental Health and Safety Office, Sortcode W2K

supervisor.pdf