Interest Calculation For Compensation Due {D-27}

INTEREST CALCULATION FOR COMPENSATION DUE (Pursuant to NRS 616C.335) INJURED EMPLOYEE: EMPLOYER: SOCIAL SECURITY NUMBER: INSURER: CLAIM NO.: TPA: (1) 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 * A+1 / 2 = "B" TOTAL = B * B-1 / 2 = TOTAL INTEREST DUE "A" TOTAL - "B" TOTAL * C *.00024641 = (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: *.00024641 * DAYS = INTEREST DUE PREPARED BY: DATE: D-27 (rev. 7/99)