Free D-27 - Nevada

INTEREST CALCULATION FOR COMPENSATION DUE (Pursuant to NRS 616C.335) INJURED EMPLOYEE: SOCIAL SECURITY NUMBER: CLAIM NO.: (1) EMPLOYER: INSURER: TPA: TO BE USED FOR COMPENSATION AND REHABILITATION PAYMENTS ONLY
DATE PRECEDING PAYMENT DATE: A LESS FIRST PAYMENT DUE: NO. DAYS OF EARNED INTEREST: A=

DATE PRECEDING PAYMENT DATE: B LESS LAST PAYMENT DUE: NO. DAYS OF EARNED INTEREST: B= C DAILY COMPENSATION RATE: C=

DAILY RATE OF INTEREST PER $1.00 @ 9% = .00024641 LEGEND: (+ = ADD) (- = SUBTRACT) (* = MULTIPLY) (/ = DIVIDE) "A" TOTAL = A "B" TOTAL = B * A+1 * B-1 TOTAL INTEREST DUE "A" TOTAL - "B" TOTAL *C *.00024641 = /2= /2=

(2)

TO BE USED FOR LUMP SUM PAYMENTS, I.E.; PPD AWARDS, REIMBURSEMENTS FOR MEDICAL TREATMENT, TRAVEL, PRESCRIPTIONS
FORMULA: (LUMP SUM AMOUNT) * (FACTOR .00024641) *(NUMBER OF DAYS) = INTEREST DUE EXAMPLE: $150 * .00024641 * 56 DAYS = $2.07

FIRST PAYMENT DUE DATE: DATE PAYMENT MADE: LUMP SUM: * DAYS PREPARED BY: = INTEREST DUE DATE: D-27 (rev.7/99) *.00024641