Form D-25 at a glance
What it is: State of Nevada, Division of Industrial Relations, Affirmation of Compliance with Mandatory Industrial Insurance Requirements, D-25, pursuant to NRS 244.33505 and NRS 268.0955.
Who signs: Only one applicant signature and date will be provided.
Applicant is the person executing this document: I declare that I have authority to act on behalf of the business, and am applying for a license to operate said business.
A filled-in Form D-25 example: a sole proprietor with workers' compensation insurance
How to fill out Form D-25, box by box
Business Name, Type of Business, Federal Employer Identification Number and Principal Owner
The top section will be completed with information about the business and ownership: Business Name (Include any name doing business as), Type of Business, Business Telephone Number, Business Address, City, State, Zip Code, Federal Employer Identification Number, Contractor's Board License Number, Name of Principal Owner (Please Print), Principal Owner's Telephone Number, Principal Owner's Address, City, State and Zip Code.
Business Name is the name under which the business will operate, including the identification of any other names under which the entity will do business.
Principal Owner is the owner, sole operator, designated general partner, or resident agent for the corporation.
Identified as: (Complete one section only)
The middle section consists of three boxes. Only one box must be checked.
Check the first box, if the business has obtained workers' compensation insurance as required by Chapter 616A to D, inclusive, of the Nevada Revised Statutes (NRS). Provide the insurance policy effective date and policy number where indicated.
Check the second box, if the business meets one of the statutory exemptions or the business has no employees nor hires any contractors/sub-contractors. The second box: the business is not subject to the provisions of Chapter 616A to D, inclusive, of the Nevada Revised Statutes, due to a statutory exemption or as a business which has no employees nor hires any independent contractor or subcontractor.
One exception to the requirement for industrial insurance is if you or your business hires no employees, subcontractors or independent contractors.
You are not required to obtain industrial insurance coverage for the following employees: theatrical or stage performers; casual musicians; household domestics, farm, dairy, agricultural or horticultural laborers, or persons engaged in stock or poultry raising; voluntary ski patrolman; real estate brokers and/or salesmen; direct sellers; or clergy.
Check the third box, if the business is self-insured with a valid certificate of insurance. Provide the self-insured policy effective date and certificate number where indicated. The third box: the business has a valid certificate of self-insurance pursuant to Chapter 616A to D, inclusive, of Nevada Revised Statutes.
Applicant: Individual, Sole Proprietor, Partnership or Corporation
In the next to bottom section, check the appropriate box indicating the license application type. The section: I declare that I have authority to act on behalf of the business, and am applying for a license to operate said business as a(n): Individual, Sole Proprietor, Partnership or Corporation.
Provide applicant information as indicated: Name of Applicant (Please Print), Applicant's Telephone Number, Applicant's Residence Address, City, State and Zip Code. Applicant is the person executing this document.
Individual is a person who operates a business which hires no employees, subcontractors or independent contractors.
Sole proprietor is a self-employed owner of an unincorporated business and includes working partners and members of working associations which may or may not hire employees.
Partnership is a business which is owned and operated by two or more individuals who share ownership rights to the net profits of the business and who share in all the liabilities of that business. A limited partnership is included in the term partnership if the limited partners are investors only, and do not perform services for the business.
Corporation is a business which is incorporated in the state of Nevada or in any other state, and which is recognized as an active corporation by the Secretary of State for the State of Nevada.
Executed on (date) and (signature)
If the form is executed in Nevada, applicant will sign and date the first line. First line (box 1): Pursuant to Nevada Revised Statutes (NRS) 53.045, I declare under penalty of perjury that the foregoing is true and correct.
If the form is executed outside of Nevada, applicant will sign and date the second line. Second line: Except as otherwise provided in NRS 53.250 to 53.390, inclusive, I declare under penalty of perjury under the law of the State of Nevada that the forgoing is true and correct.
More rules for Form D-25
Subcontractors and independent contractors engaged in the same trade, business, profession or occupation as the hiring person or business, are by law considered to be employees.
Businesses which elect to obtain industrial insurance coverage for such persons, gain valuable rights and significantly reduce liabilities for injuries to these persons. A business which hires exempt persons may elect to obtain industrial insurance, including sole proprietor coverage and partnerships.
A business which hires persons who are exempt from the provisions of Chapter 616A to 617, inclusive, of the Nevada Revised Statutes may be held liable in tort for injuries to those persons.
Common questions about Form D-25
Is there a penalty?
Pursuant to the provisions of NRS 616D.200(1): Any employer within the provisions of NRS 616B.633 who fails to provide, secure or maintain compensation as required by the terms of this chapter, is: (a) for the first offense, guilty of a misdemeanor and (b) for a second or subsequent offense committed within 7 years after the previous offense, guilty of a category D felony.
Sources
[1] Form D-25 (rev. 12/24), Affirmation of Compliance with Mandatory Industrial Insurance Requirements, Nevada Division of Industrial Relations (the Official source link on this page).