Permanent Total Disability Report Of Employment
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Permanent Total Disability Report Of Employment Form. This is a Nevada form and can be use in Workers Comp.
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Tags: Permanent Total Disability Report Of Employment, D-14, Nevada Workers Comp,
PERMANENT TOTAL DISABILITY
REPORT OF EMPLOYMENT
Pension No.
Please provide the earnings information for the periods shown below. Misrepresentation of the information requested is
fraud and is a violation of Nevada law.
Earnings are defined as wages, including overtime, commissions, salary, vacation, holiday and sick leave, termination
pay, bonuses, tips declared for the purpose of receiving workers' compensation insurance after July 1, 1985, or other
remuneration received from an employer for services rendered.
MONTH
YEAR
AMOUNT OF EARNINGS
1. ____________________________ _________
$_____________________
2. ____________________________ _________
$_____________________
3. ____________________________ _________
$_____________________
4. ____________________________ _________
$_____________________
5. ____________________________ _________
$_____________________
6. ____________________________ _________
$_____________________
7. ____________________________ _________
$_____________________
8. ____________________________ _________
$_____________________
9. ____________________________ _________
$_____________________
10.____________________________ _________
$_____________________
11.____________________________ _________
$_____________________
12.____________________________ _________
$_____________________
I hereby declare that the earnings information provided above is correct to the best of my knowledge and that there has
been no willful concealment, evasion, or enlargement of that information.
Signature
Date
Name
Social Security No.
(Month, Day, Year)
Address (P.O. Box, Apt., Street)
City, State, Zip Code
D-14 (rev. 7/99)
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