PERMANENT PARTIAL DISABILITY AWARD CALCULATION WORK SHEET Injured Employee: DOB: Sex: SS #: *Average Monthly Wage: DOI: *State Average Wage: Claim #: Date of Rating: Date Award Offered: Date Evaluation Report Received: Description: Body Basis - Verification % % Total % BB Installment Calculation * A. **.005 **.006 x **.0054 x % BB = $ B. C. Monthly Wage x 12 Monthly Rate /365.25 Annual Rate Monthly Rate =$ Year of Birth *** + Last TTD, TPD, or DOI + 5 Yr. Annual Rate =$ (1) Last Date TTD or TPD Paid: Daily Rate Installment Calculation First Payment Date: through (b)**** (2) Time Covered by First Payment: (a) ****** DOI/date of claim reopening or day after last TTD/TPD +$ +$ (3) First Payment: $ ( ) Day(s) ( ) Month(s) ( ) Year(s) through (4) Time Covered by Annual Payments: =$ =$ **** ( ) Years (5) Time Covered by Final Payment: (6) Final Payment: $ ( ) Month(s) ***** Monthly [ ] Annual [ ] through +$ =$ ( ) Day(s) Total of Installment Payments: $ .5% X % BB X Minimum Lump Sum Calculation Monthly Wage from (A) above: $ Minimum Lump Sum Amount (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) Lump Sum Calculation of Disability Up To and Including 25% (Use form D-9b for disability greater 25%) Effective Date of Award (year, month following 2 b) Per NAC 616C.502 Date of Birth (year, month) Injured Employee Age at Award Effective Date = (7) minus (8) (years, months) Monthly Rate from (B) $ Factor from Table for Present Value X Insert sum of (3). Add to sum of (11) only. Subtotal of (11) plus (12): Greater of (13) Full Lump Sum or Minimum Lump Sum: Minus any applicable award payments previously paid: 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 American LegalNet, Inc. www.FormsWorkFlow.com (rev.1/12)