Employee Death Notices Templates - Free Download
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Employee Death Notices Templates
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
INSURANCE CARRIER
EMPLOYER: ______________________________________ OR ADJUSTING AGENT: ______________________________________
STREET: _________________________________________ STREET: __________________________________________________
CITY/STATE: ________________________ ZIP: __________CITY/STATE: ______________________________ ZIP: ____________
TELEPHONE: ______________________________________ TELEPHONE: _______________________________________________
(INCLUDE AREA CODE) (INCLUDE AREA CODE)
BY:______________________________________________
TITLE: ____________________________________________
DATE: -------------------------------------------------------------------------
DIA 510 (REV. 9/84)
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source: dir.ca.gov
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