Free Form D-10b - Nevada

Injured Employee: Claim No: Employer:

Date: Date of Injury: Insurer: ELECTION OF METHOD OF PAYMENT OF COMPENSATION FOR DISABILITY GREATER THAN 25% (Pursuant to NRS 616C.495(1)(c))

I, (Name) (Social Security Number) have been advised that I may elect to receive my permanent partial disability compensation on an installment basis or; on a lump sum basis of 25%, plus installment payments on the balance of ___________% of my percentage of disability. Should I elect to receive my compensation on an installment basis, payments will begin on _______________ and terminate on _______________ and will be paid at the *monthly/annual rate of $_______________ for a total installment payment of $______________. If I elect to receive my entitlement of 25% on a lump sum basis, I will receive approximately $____________. This will vary depending on the date I elect to receive my lump sum payment. According to NRS 616C.495(1)(c), if I elect to receive my payment for permanent partial disability in a lump sum, the balance of _________% will be paid on an installment basis. Payments will begin on _________________ and terminate on ________________ and will be paid at the *monthly/annual rate of $ ______________, for a total of installment payments of $ ______________ plus lump-sum payment of $ _______________, for a total of $________________. My acceptance of the lump sum payment constitutes a final settlement of all factual and legal issues regarding this claim. By so accepting, I waive all of my rights regarding the claim, including the right to appeal from the closure of the case or the percentage of my disability, except: (a) (b) My right to request reopening in accordance with the provisions of NRS 616C.390; and Any services for counseling, training or other rehabilitation services provided by the insurer.

Further, I realize that I have twenty (20) days after the mailing or personal delivery of this notice within which to retract or reaffirm my request for a lump sum. I also realize that I will not be paid a lump sum until I have reaffirmed this election in writing. Check one to indicate method of payment desired and sign below. 1. [ ] On an installment basis as provided by NRS 616C.490. 2. [ ] A lump sum of approximately $ **____________________, with the remaining installment balance of as calculated pursuant to NRS 616C.495. $ DATE: DATE: INJURED EMPLOYEE: WITNESS: D-10b (rev. 7/99)

* Insurer: Designate whether monthly or annual rate. ** Amount depends on actual effective date (date elected).