KENNY GUINN Governor ROGER BREMNER Administrator STATE OF NEVADA CHARLES J. VERRE Chief Administrative Officer SYDNEY H. WICKLIFFE, CPA Director (775) 684-7270 Fax: (775) 687-6305 http:/dirweb.state.nv.us/ DEPARTMENT OF BUSINESS AND INDUSTRY DIVISION OF INDUSTRIAL RELATIONS Workers’ Compensation Section Capitol Complex 400 West King Street, Suite 400 Carson City, Nevada 89703 Workers’ Compensation Section NON-COMPLIANCE PREMIUM (Assessed per NRS 616D.200) Policy Name/DBA: Account Number: Primary/Location Address/Zip Code: Telephone: PERIOD FROM: RISK CLASS TO: PAYROLL RATE MOD TOTAL $ $ $ $ Estimated $ $ Uninsured premium from: $ $ to: $ Total Premium Reopen Effective Date: Reopening Cost: Audited New Coverage Effective Date: AMOUNTS ARE SUBJECT TO CHANGE BY AUDIT Employer’s Acknowledgement of Receipt Date Insurer Representative (Print Name) Date Right of Appeal Pursuant to the rules and regulations of the Workers’ Compensation Section, should any party desire to protest this determination, a written notice of protest must be filed with the Workers’ Compensation Section at the above address within thirty (30) days after receipt, requesting a formal hearing before the Administrator’s designated Hearings Officer. Please attach a written statement detailing your basis for appeal. D-40cc (rev. 02/04) American LegalNet, Inc. www.USCourtForms.com