Free D-21 - Nevada

STATE OF NEVADA DEPARTMENT OF BUSINESS AND INDUSTRY Division of Industrial Relations 400 West King Street, Suite 400 1301 N. Green Valley Parkway, Suite 200 Carson City, Nevada 89703 Henderson, Nevada 89074 FATALITY REPORT (Pursuant to NAC 616B.018) (Note: The insurer must notify the Administrator within 48 hours after receiving notice of fatality) To: From: Address: Date: ADMINISTRATOR, D.I.R.

Deceased: Address: County:

D.O.B. City: State: Time:

SSN:

Date of Accident or onset of Occupational Disease: Date of Death: Marital Status: Name of Dependent: Name of Dependent: Name of Dependent: Employer: Address: Deceased Employee's Occupation: Exact Location of Accident (if applicable): Name of Spouse: D.O.B. D.O.B. D.O.B.

A.M. P.M.

No. of Dependents: Relationship: Relationship: Relationship:

Type of Business:

Describe Accident or Occupational Disease:

Reported By Title D-21 (rev. 7/99)