Section 616C.274 - Form for requesting hearing before hearing officer or for notice of appeal; information required to be provided by insurer or third-party administrator1. A request for a hearing before a hearing officer or a notice of appeal filed with the Hearings Division must be filed: (a) On a form provided by an insurer, an organization for managed care or the Hearings Division; or(b) On a similar form approved by the Department of Administration.2. An insurer or the third-party administrator for an insurer shall provide the following information on each form used to request a hearing:(a) The name and last known mailing address of the claimant;(b) The name under which the employer was doing business at the time of the injury and the last known mailing address and telephone number of the employer;(c) If the insurer is a self-insured employer:(1) The name, address and telephone number of the self-insured employer; and(2) The name, address and telephone number of the third-party administrator of the self-insured employer, if any;(d) The number of the claim; and(e) The date of injury or, in the case of occupational disease, the estimated or approximate date of injury.Nev. Admin. Code § 616C.274
Added to NAC by Hearings Div., eff. 5-23-96; A by R184-07, 9-29-2008