Dia Form 510 Notice Of Employee Death California Department Of Industrial Relations

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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: _______________________________________________