Is Your C-4 Form – Employees Claim for Compensation/Report of Initial Treatment – Filled Out Correctly?

One of the most common issues that we encounter handling workers’ compensation claims is improper reporting on the C-4 form. Mistakes made on the C-4 form at the outset of the claim can cause big headaches for you, the injured worker, that last throughout the claim. However, by following a few short and simple tips, you can easily navigate this potential barrier to fully recover all the benefits you are entitled to under Nevada’s workers’ compensation system.

I will not overstate the obvious: do be sure to complete all the demographic questions: i.e. name, address, birth date, height, weight, etc. Most people get that right and of course whether or not you are male of female will hardly cost you your claim! It’s not until we get down to the important stuff that things can get hairy. Eighth line down is where the important and critical information starts.

The date of injury

Make sure that this is the exact day you were injured and hopefully the day that you reported your injury to your employer! All too often we see claims denied because a judge does not believe an injury actually occurred because the injured worker blithely put down facts that are later refuted by an aggressive defense attorney.

Date Employer notified

This is where things get tricky. The rules read that you are to report your injury “as soon as practical, but within seven days after the accident”. So why is it so important if you have seven days to report it? The answer is your burden of proving an injury actually occurred at work, instead of at home, will increase exponentially if you hurt your back at work and then go home with hopes of relief from a heating pad and Advil, just to find that you can’t get out of bed in the morning. The single most important piece of advice we can give…. report it right away! Even if you think you will get better without going to the doctor. You cannot un-ring this bell! No report, no claim. Under Nevada law, a C-1 form “Notice of Injury or Occupational Disease Incident Report” must be filled out and turned in to your employer for all injury and occupational disease claims. If your employer does not have a C-1 form handy or if you cannot print one yourself, write it on a napkin, a scrap of paper, a McDonald’s bag or something else if you must! A wise man once said, “A verbal contract isn’t worth the paper it’s written on.” This is doubly true for verbal notices to your employer after a work injury.

Last Day of Work After Injury or Occupational Disease

This may be the day you were injured on the job.

Supervisor to Whom Injury was Reported

This is your boss. Whomever is in charge of you.

Address of the Accident

Where were you? This is important. Depending on where you were at the time you got injured, there may be a third party claim for compensation as well.

What were you doing at the time of the accident AND How did the injury or occupational disease occur?

Be very specific. The devil is in the details here. You’ve got a little box to give big information so spell it out! Omission of facts in this area can cost you your claim. Be sure to specifically identify what caused you to injure yourself. Whether there was a crack on the floor, a wrinkle in the carpet, or you were simply hurrying to complete a work task and tripped, make sure you write it down. An “I don’t know” in this box most likely means your claim will be denied. The key to this section is to specifically identify some risk associated with your employment as the cause of your injury. If you can do that, your claim will most likely be accepted.

Witnesses to the Accident

List everyone that witnessed the accident. If you are not sure if they witnessed the accident, say you are not sure if they saw it or not, say so and list them out.

Nature of Injury

i.e. sprain/strain/contusion/bruise/laceration

Parts of Body Injured or Affected

LIST ALL BODY PARTS that are or may be injured. It is very difficult to add additional body parts after the fact, so if you think it hurts, tingles, itches, or is numb, list it. It is much better to be safe than sorry here.

Date it, sign it, and list the facility you went to.

Your part is done!

The bottom half of the form is filled out by the doctor. If you are wise, you will review this before you leave the hospital or facility. Many doctors are in a hurry and make mistakes on the form. You didn’t want to be here in the first place, the last thing you want to do is come back, so make sure that the doctor has filled out ALL the boxes.

• Make sure that the doctor lists all the same body parts that you listed.
• Make sure that the doctor connects your injury to your job.
• Make CERTAIN that if the doctor gives you time off from work, that he/she lists the form and two dates.
• If there are restrictions, insure that they are clear and concise.
• If the doctor wants you to follow up, WHEN AND WHERE!
• Last but not least, make sure that the doctor signs the form. The form is not valid unless it is signed.

By following these tips, you will find that you can avoid many common pitfalls for injured workers in Nevada. We have only covered the topic of industrial accidents here. In a later posting we will cover industrial diseases under the Nevada Industrial Insurance Act.

As always, if you are in need of aggressive Las Vegas workers’ compensation attorney experienced in Nevada workers’ compensation procedures, we provide free consultations and will be happy to answer all of your questions.