Form D 25 PDF Details

Form D 25 is an important document that businesses use to report their annual financial information. This document is used by businesses to file their taxes and can help them qualify for certain tax benefits. In order to complete Form D 25, businesses will need to gather a variety of financial documents including their balance sheet, income statement, and statement of cash flows. Completing Form D 25 can be a complicated process, but it's important for businesses to do so in order to stay compliant with the law. By understanding the requirements of Form D 25 and gathering the necessary documents, businesses can ensure that they are completing this form correctly.

Form NameForm D 25
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other names616A, division of industrial relations affirmation of compliance form, state industrial insurance affirmation of compliance form d 25, state industrial insurance affrimation compliance

Form Preview Example






Business Name (Include any name doing business as)Type of BusinessBusiness Telephone Number


Business AddressCityStateZip Code


Federal Identification No.Social Security No.Contractor’s Board License No.


Name of Principal Owner (Please Print)Principal Owner’s Telephone No.


Principal Owner’s Address



Zip Code

Identified as: (Complete one section only)

() That the above identified business has obtained industrial workers’ compensation insurance as required by Chapter

616A to D, inclusive, of the Nevada Revised Statutes (NRS):



Effective Date of Coverage

Account Number

() That the above identified 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.

() That the above identified business has a valid certificate of self-insurance pursuant to Chapter 616A to D, inclusive, of Nevada Revised Statutes.



Effective Date

Certificate Number

I declare that I have the authority to act on behalf of the above described business, and am applying for a license to

operate said business as a (n):

( ) Individual ( ) Sole Proprietor ( ) Partnership ( ) Corporation


Name of Applicant (Please Print)Applicant’s Telephone Number


Applicant’s Residence Address



Zip Code

I do hereby affirm that the above information is true and correct.

DATED this _______________ day of ___________________, 20______.


Signature of Applicant (To be signed in the presence of the business license office employee)

Applicant’s Title



Witness Signature - (Business License Office Employee)

Name of City or County


If unable to sign this document in the presence of a Business License Employee, the Applicant’s signature must be notarized.

SUBSCRIBED and SWORN to before me on this _________ day of ___________________, 20____.



D-25 (1) (rev. 3/01)


The provisions of Chapter 616A to D, inclusive, of the Nevada Revised Statutes require every person, firm, voluntary association, and private corporation, including any public service corporation, which has any person, subcontractor, or independent contractor, under contract of hire, to obtain industrial insurance coverage in Nevada or obtain a certificate of self-insurance from the Nevada Commissioner of Insurance. 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. 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 patrolmen; real estate brokers and/or salesmen; direct sellers; or clergy. 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 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. A business, which hires exempt persons, may elect to obtain industrial insurance, including sole proprietor coverage and partnerships.

IMPORTANT NOTICE: 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.

Definitions for Purposes of this Affirmation:

“Applicant” is the person executing this document

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.

“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.

“Type of Business” means the nature of the business…

“Individual” is a person who operates a business which hires no employees, subcontractors, or independent contractors.

“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.

“Principal Owner” is the owner, sole operator, designated general partner, or resident agent for the corporation.

“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.

D-25 (2) (rev. 3/01)

How to Edit Form D 25 Online for Free

state of nevada disvioson of industrial relations affirmations of compliance can be filled out very easily. Just try FormsPal PDF tool to get it done fast. The editor is continually maintained by our staff, receiving handy functions and becoming a lot more versatile. It merely requires several basic steps:

Step 1: Just press the "Get Form Button" in the top section of this site to access our pdf editing tool. Here you will find all that is needed to work with your file.

Step 2: When you launch the editor, you'll see the form all set to be filled in. Besides filling out different fields, you may also perform other things with the PDF, namely putting on any words, changing the original text, adding images, signing the document, and a lot more.

Pay close attention while filling out this form. Ensure that every blank is completed correctly.

1. The state of nevada disvioson of industrial relations affirmations of compliance necessitates particular details to be inserted. Be sure that the following blank fields are finalized:

616B conclusion process outlined (step 1)

2. After filling in the previous step, go on to the next part and fill in all required particulars in these blank fields - That the above identified business, Business Name Include any name, I declare that I have the, Corporation, Certificate Number, Name of City or County, DATED this day of, Applicants Telephone Number, Applicants Title, Zip Code, State, and City.

616B conclusion process clarified (step 2)

Be really mindful while filling out Zip Code and Name of City or County, since this is the section where a lot of people make errors.

3. This next part is going to be easy - fill out all of the blanks in Business Name Include any name, and D rev in order to finish this part.

616B writing process explained (part 3)

Step 3: Proofread everything you have inserted in the form fields and click on the "Done" button. Obtain your state of nevada disvioson of industrial relations affirmations of compliance the instant you register online for a free trial. Quickly view the pdf file within your FormsPal cabinet, along with any edits and changes automatically preserved! We don't sell or share the details you use while filling out forms at our website.