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2. 
3. REPORT THE DEATH OF AN EMPLOYEE OR MEMBER

   We are sorry for your loss. Although this is a difficult time, it’s crucial to report the death of an employee or member as soon as possible.  Our staff will be in contact within 1-2 business days.

5. YOUR INFORMATION

   The person reporting the death of an employee or member

7. First Name *
8. Last Name*
10. Email
11. Re-enter Email
13. Phone Number
15. What is your relation to the deceased?
    -- Select One --SpouseSonDaughterMotherFatherSisterBrotherOther
19. DECEASED EMPLOYEE OR MEMBER INFORMATION
21. First Name of Deceased*
22. Middle Name or Initial of Deceased
23. Last Name of Deceased*
25. Employee ID/Member Number

    Please enter City of Norfolk Employee ID or NERS Retirement ID number.

26. Last 4 digit of SSN

    Please enter last 4 digits of deceased employee or member's Social Security number.  No dashes.

28. Date of Death*
    Date of Death

    Please pick the date.

30. Is the Deceased Married?

    1. Yes
    2. No
32. Next of Kin First Name
33. Next of Kin Last Name
34. Next of Kin Phone Number
36. ADDRESS OF DECEASED
38. Address1
40. Address2
42. City
43. State
44. Zip
46. Additional Information/Comments
48. Once a death is reported, what types of documents are required to process a claim?

    A certified original death certificate must be submitted to the NERS before any benefits are paid to a beneficiary(s) or decedent’s estate. Additionally, other documents may be requested in order to complete the process. 

Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field