Free D-46 - Nevada

Temporary Partial Disability Calculation Worksheet
(NAC 616C.598(7))

For Claims Agent's Use
Injured Employee Insurer Third-Party Administrator Employer Claim Number Pay Period (From) Pay Period (To) / / / / SSN Paid: Weekly Bi-Weekly Semi-Monthly Monthly Gross Wage SSTax/FICA Medicare FIT/FWT $ $ $ $ Reason for Absence: Days Not Included in Pay Period

Other (define) $ Net Wage $

(after the usual deductions are made for social security, income taxes and other required state or federal deductions) Pursuant to NAC 616C.598(2). TTD (for the same period) Net Wage $

$

TPD due $ (if the net pay is greater than the TTD rate, there is no entitlement to TPD) Pursuant to NAC 616C.598(1).

Prepared By

Date

D-46 (7/99)