Injured Employee: Claim No: Employer: Date: Date of Injury: Insurer: ELECTION OF METHOD OF PAYMENT OF COMPENSATION (Pursuant to NRS 616C.495) NRS 616C.495(2) provides: 2. If the injured employee elects to receive his payment for a permanent partial disability in a lump sum, all of his benefits for compensation terminate. His acceptance of that payment constitutes a final settlement of all factual and legal issues in the case. By so accepting he waives all of his rights regarding the claim, including the right to appeal from the closure of the case or the percentage of his disability, except: (a) His right to reopen his claim according to the provisions of NRS 616C.390; and (b) Any counseling, training or other rehabilitative services provided by the insurer. (c) The right of the claimant to receive a benefit penalty in accordance with NRS 616D.120. The claimant, when he or she demands payment in a lump sum, must be provided with a written notice which prominently displays a statement describing the effects of accepting payment in a lump sum of an entire permanent partial disability award, any portion of such an award or any uncontested portion of such an award, and that the claimant has 20 days after the mailing or personal delivery of the notice within which to retract or reaffirm the demand, before payment may be made and the claimant's election becomes final. I, (Name) (Social Security Number) have been advised that I may elect to receive my permanent partial disability compensation on an installment basis or, if eligible, and I so elect, on a lump sum basis. Should I elect to receive my compensation on an installment basis, payments will begin on and will be paid at the *monthly/annual rate of $ on . payment of $ and terminate for a total installment . This sum will If I elect to receive my entitlement on a lump sum basis I will receive approximately $ vary depending on the date I elect to receive my lump sum payment. As provided by NRS 616C.495, if I elect to receive my payment for permanent partial disability in a lump sum, all of my benefits for compensation terminate. My acceptance of the lump sum payment constitutes a final settlement of all factual and legal issues in this case, including but not limited to unresolved issues that are or could become the subject of pending litigation,. By so accepting, I waive all of my rights regarding the claim, including, but not limited to, the right to appeal from the closure of the case or the percentage of my disability, except: (a) (b) My right to request reopening in accordance with the provisions of NRS 616C.390; and Any counseling, training or other rehabilitation services provided by the insurer. Further, I understand that I have twenty (20) days after this notice has been mailed or personally delivered to me, within which to retract or reaffirm my request for a lump sum. I also understand that I will not be paid a lump sum until I have reaffirmed this election in writing. I also understand that any lump sum I receive is subject to an offset based on any prior PPD payments I received before electing to accept a lump sum. Check one to indicate method of payment desired and sign below. 1. [ ] On an installment basis as provided by NRS 616C.490. as calculated pursuant to NRS 616C.495. 2. [ ] A lump sum of approximately $ ** DATE: DATE: INJURED EMPLOYEE: WITNESS: * Insurer: Designate whether monthly or annual rate. ** Amount depends on actual effective date (date elected). D-10a (Rev. 10/10) American LegalNet, Inc. www.FormsWorkFlow.com