NAC616C.274. Form for requesting hearing before hearing officer or for notice of appeal; information required to be provided by insurer or third-party administrator.

     1. 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.

     (Added to NAC by Hearings Div., eff. 5-23-96; A by R184-07, 9-29-2008)