STATE OF NEVADA
STATE OF NEVADA
Department of Business and Industry
Division of Industrial Relations
Summary of Claims Expenditures
Workers’ Compensation Claims Expenditures
January 1, 2019 – June 30, 2019
1) «DBA»
Claims Expenditure Information:
|(Please round all amounts to the nearest |Non-Mining: |Mining: |Total: |
|dollar) | | | |
| |(2) |(3) |(4) |
|January 1, 2019, through June 30, 2019 | | | |
|(For injuries on or after 7/1/99) | | | |
| |$________________ |$________________ |$________________ |
(5) Does this report include all entities covered under the Certificate of Insurance for the insurer listed above?
( ) YES ( ) NO
(6) Insurer’s Federal Tax I.D. Number: _________________________________________________
Please complete and return this form Compiled and approved on behalf of the above
No later than August 31, 2019, to: Insurer by:
Division of Industrial Relations ______________________________________
1830 College Pkwy, Suite 100 Insurer or Third-Party Administrator
Carson City, NV 89706
Attn: WCS Assessments ______________________________________
Signature Date
Or at e-mail address
BI-fiscalunit@business.
______________________________________ Name (Please type or print) Phone #
______________________________________
Address of Intended Recipient
*Please see instructions
______________________________________ City, State, ZIP
______________________________________ Email
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