STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION FORWARD TO P.O. BOX 422400 SAN FRANCISCO CA 94142 NOTICE OF EMPLOYEE DEATH ============================================================================================================ EACH EMPLOYER SHALL NOTIFY THE ADMINISTRATIVE DIRECTOR OF THE DEATH OF EVERY EMPLOYEE REGARDLESS OF THE CAUSE OF DEATH EXCEPT WHERE THE EMPLOYER HAS ACTUAL KNOWLEDGE OR NOTICE THAT THE DECEASED EMPLOYEE LEFT A SURVIVING MINOR CHILD (TITLE 8, CHAPTER 4.5, SECTION 9900). ============================================================================================================ DECEASED EMPLOYEE: NAME: ____________________________________________ AGE: ______ SOCIAL SECURITY NUMBER: _______________________ LAST KNOWN ADDRESS: _______________________________________________________________________________________ NAME, RELATIONSHIP AND LAST KNOWN ADDRESS OF NEXT OF KIN: ___________________________________________________ ____________________________________________________________________________________________________________ JOB TITLE AND NATURE OF DUTIES: ______________________________________________________________________________ ____________________________________________________________________________________________________________ DATE, TIME AND PLACE OF ACCIDENT: ____________________________________________________________________________ DATE, TIME AND PLACE OF DEATH: ______________________________________________________________________________ CIRCUMSTANCES OF DEATH (DESCRIBE FULLY THE EVENTS WHICH RESULTED IN DEATH. TELL WHAT HAPPENED. USE ADDITIONAL SHEET IF NECESSARY): ____________________________________________________________________________________________________________ CAUSE OF DEATH (ATTACH COPY OF DEATH CERTIFICATE OR CORONER'S REPORT): ____________________________________________________________________________________________________________ HAVE ANY WORKERS' COMPENSATION DEATH BENEFITS BEEN PROVIDED IN CONNECTION WITH THIS DEATH? _____YES _____ NO IF YES, TO WHOM: ____________________________________________________________________________________________ ATTACH A COPY OF THE FORM 5020, "EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS," IF ONE WAS FILED. .................................................................................................................................................................................... PLEASE NOTE: IF THE DEATH IS WORK-RELATED, THE EMPLOYER ALSO IS REQUIRED TO REPORT THE DEATH TO HIS OR HER WORKERS' COMPENSATION INSURANCE CARRIER AND TO THE NEAREST OFFICE OF THE DIVISION OF INDUSTRIAL SAFETY IMMEDIATELY BY TELEPHONE OR TELEGRAPH. AN EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS SHOULD ALSO BE FILED WITH THE WORKERS' COMPENSATION INSURANCE CARRIER. .................................................................................................................................................................................... ( ) INSURED ( ) SELF-INSURED ( ) LEGALLY UNINSURED EMPLOYER: ______________________________________ STREET: _________________________________________ INSURANCE CARRIER OR ADJUSTING AGENT: ______________________________________ STREET: __________________________________________________ CITY/STATE: ________________________ ZIP: __________ CITY/STATE: ______________________________ ZIP: ____________ TELEPHONE: ______________________________________ (INCLUDE AREA CODE) TELEPHONE: _______________________________________________ (INCLUDE AREA CODE) BY:______________________________________________ TITLE: ____________________________________________ DATE: ------------------------------------------------------------------------DIA 510 (REV. 9/84) American LegalNet, Inc. www.FormsWorkflow.com