Fill and Sign the Permanent Disability in Nevada Workers Compensation Claims Form

PERMANENT PARTIAL DISABILITY AWARD CALCULATION WORK SHEET Injured Employee: DOB: Sex: SS #: DOI: Claim #: *Average Monthly Wage: *State Average Wage: Date of Rating: Date Award Offered: Date Evaluation Report Received: Body Basis - Verification Description: % % Total % BB Installment Calculation **.005 **.006 Last TTD, * A. x **.0054 x % BB = $ Year of Birth TPD, or DOI Monthly Wage Monthly Rate *** B. x 12 = $ + + 5 Yr. Monthly Rate Annual Rate C.  365.25 = $ Annual Rate Daily Rate Installment Calculation (1) Last Date TTD or TPD Paid: First Payment Date: (2) Time Covered by First Payment: (a) through (b) **** ****** DOI/date of claim reopening or day after last TTD/TPD (3) First Payment: $ + $ + $ = $ ( ) Day(s) ( ) Month(s) ( ) Year(s) (4) Time Covered by Annual Payments: through = $ **** ( ) Years (5) Time Covered by Final Payment: through (6) Final Payment: $ + $ = $ ( ) Month(s) ( ) Day(s) ***** Monthly [ ] Annual [ ] Total of Installment Payments: $ Minimum Lump Sum Calculation .5 X % BB X Monthly Wage from (A) above: $ Minimum Lump Sum Amount Lump Sum Calculation of Disability Up To and Including 30% (Use form D-9b for disability greater 30%) (7) Effective Date of Award (year, month following 2 b) Per NAC 616C.502 (8) Date of Birth (year, month) (9) Injured Employee Age at Award Effective Date = (7) minus (8) (years, months) (10) Monthly Rate from (B) $ (11) Factor from Table for Present Value X = $ (12) Insert sum of (3). Add to sum of (11) only. + $ (13) Subtotal of (11) plus (12): $ (14) Greater of (13) Full Lump Sum or Minimum Lump Sum: $ (15) Minus any applicable award payments previously paid: - $ (16) Net Amount Payable: $ * Use the Average Monthly Wage or the State Average Wage, whichever is lower. If the average monthly wage (AMW) for TTD on this claim is subject to the frozen 1993 rate, recalculate the AMW for PPD purposes. ** Use .005 for injuries sustained before 07/01/81. Use .006 for injuries sustained after 07/01/81, through 06/17/93. Use .0054 for injuries sustained on or after 06/18/93. Use .006 for injuries sustained on or after 1/1/00. *** Per NRS 616C.490(7), age at which entitlement ceases. **** This must reflect the end of the month prior to election of the award. Recalculation may be required to bring the award to present day value. If (2)(b) is December date, use caution on line (4) to assure correct number of years. (If subtracting dates, add one year) ***** Must pay monthly installments if monthly entitlement is $100 or more. May pay annual installments if monthly entitlement is less than $100. ******Use date of claim reopening if TTD/TPD benefits were not paid after the claim was reopened (2)(a). PREPARED BY: DATE: CHECKED BY: DATE: D-9a (rev.12/ 16)