STATE OF NEVADA DEPARTMENT OF BUSINESS AND INDUSTRY Division of Industrial Relations 400 West King Street, Suite 400 3360 West Sahara Avenue, Suite 250 Carson City, Nevada 89703 Las Vegas, Nevada 89102 FATALITY REPORT (Pursuant to NAC 616B.018) (Note: The insurer must notify the Administrator within 48 hours after receiving notice of fatality) To: ADMINISTRATOR, D.I.R. From: Address: Date: Deceased: D.O.B. SSN: Address: City: County: State: A.M. Date of Accident or onset of Occupational Disease: Time: P.M. Date of Death: Marital Status: Name of Spouse: No. of Dependents: Name of Dependent: D.O.B. Relationship: Name of Dependent: D.O.B. Relationship: Name of Dependent: D.O.B. Relationship: Employer: Type of Business: Address: Deceased Employee's Occupation: Exact Location of Accident (if applicable): Describe Accident or Occupational Disease: Reported By Title D-21 (rev 6/18) American LegalNet, Inc. www.FormsWorkFlow.com