Office Of Risk Management

500 S. Grand Central
Las Vegas, Nevada 89155
(702) 455-4544
Business Hours: Monday – Thursday 7:30 am – 5:30 pm

PRNR#

Guarantor Last 4 SSN#

Guarantor Last Name

First Name

Employer Name

Insurance Name

Coverage Tier

Month of Coverage (Select all that apply)

Payment Type

Payment For

Payment Amount

Contact Phone

Email Address

Address

City

State

Zip Code

Member Comments

A convenience fee of 2.65% of total fees will apply to each credit card payment.
The convenience fee is collected by a third party and will be represented on your credit card statement as a separate transaction.