Deceased employee: þ First þ þ Middle þ þ LastDate of birth: Social Security number: Address at time of death: City: State: ZIP: Surviving Spouse, Dependents or Heirs Name þ Address þ Email Date of Birth þ Relationship þ Date(s) of accident/repetitive trauma/occupational disease: Time: : A.M. P.M. Date of death: How did accident/repetitive trauma/disease occur? Federal Privacy Act Disclosure Section 7(a)(2)(B) þby Section 7(a)(2)(B) of the Federal Privacy Act of 1974, since our regulations which require its disclosure were in existence before January 1, þ The use of Social Security numbers is made necessary because of the large number of applicants who have similar names and birth dates, and whose identities can only be distinguished by the Social Security number. DO NOT WRITE IN THIS SPACE DO NOT WRITE IN THIS SPACE DIVISION OF WORKERS COMPENSATION þ Applicant printed name þ Signature þ Date Address: American LegalNet, Inc. www.FormsWorkFlow.com