Employees Claim For Compensation - Uninsured Employer {D-17}

D-17 - EMPLOYEE'S CLAIM FOR COMPENSATION - UNINSURED EMPLOYER. This form is used by an employee in Nevada to file a workers’ compensation claim when they have been injured on the job while working for an uninsured employer—one that does not have workers' compensation insurance as required by law. This form is submitted to the Nevada Division of Industrial Relations – Workers’ Compensation Section and gathers essential information about the employee, employer, and details of the injury or occupational disease. The form requires the employee to provide their personal details, employment information, and specifics about the accident or work-related illness, including the date, time, location, and circumstances of the incident. It also asks for details about medical treatment received, the name of the treating doctor or hospital, and whether the employee was transported for medical care. Additionally, the form includes a declaration under penalty of perjury affirming the truthfulness of the information provided and an assignment of subrogation rights to the Division of Industrial Relations, which allows the state to recover costs from the uninsured employer. www.FormsWorkflow.com