KENNY GUINN Governor ROGER BREMNER Administrator STATE OF NEVADA CHARLES J. VERRE Chief Administrative Officer SYDNEY H. WICKLIFFE, CPA Director (702) 486-9080 Fax: (702) 990-0364 http:/dirweb.state.nv.us/ DEPARTMENT OF BUSINESS AND INDUSTRY DIVISION OF INDUSTRIAL RELATIONS Workers’ Compensation Section 1301 North Green Valley Parkway, Suite 200 Las Vegas, Nevada 89014 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-40lv (rev. 02/04) American LegalNet, Inc. www.USCourtForms.com