NAC695F.510. Burden of proof to claim exemption.

The operator of a program described in NAC 695F.500 has the burden of proving that the program meets the requirements of that section for exemption from chapter 695F of NRS. This burden of proof may be met by providing the Commissioner with a claim of exemption in substantially the following form:

COMMISSIONER OF INSURANCE

DEPARTMENT OF BUSINESS AND INDUSTRY

STATE OF NEVADA

CLAIM OF EXEMPTION FOR EMPLOYEE ASSISTANCE PROGRAM

     (  ) Original claim                          (  ) Amendment to claim dated:............................................

    

     1. Legal name of the person filing this claim: ...........................................................................

     2. Address of the principal office of the program and, if different, the mailing address of the program:    

     3. Fictitious names used in connection with the operation of the program (if none, so state): .

     4. Name, title, address and telephone number of a representative of the program who may be contacted regarding this claim: ..........................................................................................................................

     The undersigned hereby declares that the employee assistance program specified in this claim meets the requirements of NAC 695F.500 and is exempt from chapter 695F of NRS. The undersigned agrees to amend this claim within 30 calendar days after the occurrence of any material change in the information specified in this claim.

     Date of claim: ...............................................................................................................................

     Name of person filing claim: ........................................................................................................

     Signature of authorized officer of program: ................................................................................

     Printed name and title of authorized officer: ...............................................................................

     Verification:..................................................................................................................................

     I hereby certify or declare under penalty of perjury under the laws of the State of Nevada that I have read this claim and any attachments thereto and know the contents thereof and that the statements therein are true and correct.

     Executed at (city and state) ........................................ on the ......... day of the month of .………….. of the year   .

                                                                        ...................................................................................

                                                                                                         (Signature)

     (Added to NAC by Comm’r of Insurance, eff. 2-3-97)