Injured Employee: Social Security No.: Claim No.: Employer: Date of Injury: REAFFIRMATION/RETRACTION OF LUMP SUM REQUEST Pursuant to NRS 616C.495(2) and NAC 616C.499(1) NAC 616C.499(1) provides: If an injured employee elects to receive his award for a permanent partial disability in a lump sum, he must reaffirm his election within 20 days after receiving notification from the insurer pursuant to subsection 2 of NRS 616C.495 before the lump sum will be paid. Please indicate whether you wish to reaffirm or retract your request for a lump sum payment by checking the appropriate box below. Your decision as indicated on this form constitutes your final election regarding the lump sum payment. Failure to return this form or not checking one of the boxes may result in a delay in the processing of your award. I reaffirm the request for my lump sum payment. I understand that in doing so, I am waiving all of my rights regarding the claim, except my right to request reopening and vocational rehabilitation. I retract the request for my lump sum payment. Signature of Injured Employee Date Witness Date D-11 (rev. 7/99) American LegalNet, Inc. www.FormsWorkFlow.com