Election Of Method Of Payment Of Compensation For Disability Greater Than 25
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Election Of Method Of Payment Of Compensation For Disability Greater Than 25 Form. This is a Nevada form and can be use in Workers Comp.
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Tags: Election Of Method Of Payment Of Compensation For Disability Greater Than 25, D-10b, Nevada Workers Comp,
Injured Employee:
Claim No:
Employer:
Date:
Date of Injury:
Insurer:
ELECTION OF METHOD OF PAYMENT OF COMPENSATION
FOR DISABILITY GREATER THAN 25%
(Pursuant to NRS 616C.495(1)(c))
I,
(Name)
(Social Security Number)
have been advised that I may elect to receive my permanent partial disability compensation on an installment
basis or; on a lump sum basis of 25%, plus installment payments on the balance of ___________% of my
percentage of disability.
Should I elect to receive my compensation on an installment basis, payments will begin on _______________
and terminate on _______________ and will be paid at the *monthly/annual rate of $_______________ for a
total installment payment of $______________.
If I elect to receive my entitlement of 25% on a lump sum basis, I will receive approximately $____________.
This will vary depending on the date I elect to receive my lump sum payment. According to
NRS 616C.495(1)(c), if I elect to receive my payment for permanent partial disability in a lump sum, the
balance of _________% will be paid on an installment basis. Payments will begin on _________________ and
terminate on ________________ and will be paid at the *monthly/annual rate of $ ______________, for a total
of installment payments of $ ______________ plus lump-sum payment of $ _______________, for a total of
$________________.
My acceptance of the lump sum payment constitutes a final settlement of all factual and legal issues regarding
this claim. By so accepting, I waive all of my rights regarding the claim, including the right to appeal from the
closure of the case or the percentage of my disability, except:
(a)
My right to request reopening in accordance with the provisions of NRS 616C.390; and
(b)
Any services for counseling, training or other rehabilitation services provided by the insurer.
Further, I realize that I have twenty (20) days after the mailing or personal delivery of this notice within
which to retract or reaffirm my request for a lump sum. I also realize that I will not be paid a lump sum
until I have reaffirmed this election in writing.
Check one to indicate method of payment desired and sign below.
1. [ ] On an installment basis as provided by NRS 616C.490.
2. [ ] A lump sum of approximately $ **____________________, with the remaining installment balance of
as calculated pursuant to NRS 616C.495.
$
DATE:
INJURED EMPLOYEE:
DATE:
WITNESS:
* Insurer: Designate whether monthly or annual rate.
** Amount depends on actual effective date (date elected).
D-10b (rev. 7/99)
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