Election Of Coverage By Employer And Employer Withdrawal Of Election Of Coverage {D-44}

Election of Coverage by Employer; and Employer Withdrawal of Election of Coverage Pursuant to NRS 616B.656 Employer Name: Employer Address: Employer Telephone No.: Federal Identification No.: Employee Name: Employee Excluded Profession: Insurer: Date Notice Received to Administrator accepting provisions of NRS 616A to 616D. Effective Date: Policy #: Date Notice to Insurer: Employer Representative Signature: Title: Date of Signature: Withdrawal of Employer Election Date Notice to Administrator: Date Notice to Insurer: Employer Representative Signature: Title: Date of Signature: FOR WCS USE ONLY Method of Transmission First Class Mail [ ] Electronic Transmission/Fax [ ] Personally Served [ ] Date Notice Received: D-44 (Rev.02/04)