Injured Employee: SS #: *Average Monthly Wage: Date Award Offered: PERMANENT PARTIAL DISABILITY AWARD CALCULATION WORK SHEET FOR DISABILITY OVER 25% BODY BASIS see NRS 616C.495(1)(c) Sex: DOB: Claim #: DOI: Date of Rating: *State Average Wage: Date Evaluation Report Received: Description: Body Basis - Verification % Total % - 25% Lump Sum Balance for installment calculation: % BB % Installment Calculation * A. B. C. x Monthly Wage x 12 Monthly Rate / 365.25 Annual Rate **.005 **.006 **.0054 x % BB =$ Monthly Rate =$ Year of Birth *** + Last TTD, TPD, or DOI + 5 Yr. Annual Rate =$ (1) Last Date TTD or TPD Paid: Daily Rate Transfer (1) through (3) from form D-9a to (1) through (3) on form D-9b First Payment Date: (2) Time Covered by First Payment: (a) through (b) **** ******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: $ (from Form D-9a) $ **** ( (5) Time Covered by Final Payment: ) Years through (6) Final Payment: $ +$ = $ ***** Monthly [ ] Total of Installment Payments: $ (4) through (6) Minimum Lump Sum Calculation (Payable only if greater than total of installment on form D-9a) Monthly Wage from (A) above: $ % BB X .5% X (Use Total Percent of Disability) Minimum Lump Sum Amount X ** X 25 %BB = $ D. Average Monthly Wage Monthly Rate (from A above) (7) Effective Date of Award (year, month following 2 b) Per NAC 616C.502 (8) Date of Birth (year, month) (9) Injured Employee's Age at Award Effective Date = (7) minus (8) (years, months) (10) Monthly Rate from D $ = $ (11) Factor from Table for Present Value X (12) Insert sum of (3) + $ (13) Subtotal of (11) plus (12): $ (14) Minus any applicable award payments previously paid: $ (15) Net Amount Payable: $ ( ) Month(s) Annual [ ] ( ) Day(s) * 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: CHECKED BY: DATE: DATE: D-9b (rev. 1/12) American LegalNet, Inc. www.FormsWorkFlow.com