Fatality Report {D-21}

D-21 - FATALITY REPORT (Pursuant to NAC 616B.018). This form is used in Nevada to report a work-related death to the Division of Industrial Relations (DIR) under NAC 616B.018. The insurer handling the workers' compensation claim is required to notify the DIR Administrator within 48 hours after receiving notice of a fatality. This form collects essential details about the deceased employee, including name, date of birth, social security number, address, marital status, dependents, employer information, and the circumstances of the accident or occupational disease that led to the fatality. It also includes the date and time of the accident and death, as well as a detailed description of how the incident occurred. The purpose of this form is to ensure that state authorities are informed of workplace fatalities promptly, allowing for proper investigation, compliance with workplace safety regulations, and processing of any workers' compensation benefits for the deceased employee’s dependents. www.FormsWorkflow.com