ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 AWCB Case Number: DEATH BENEFITS REPORT Complete this form and attach to Compensation Report (Form 07-6104) when you begin, change, suspend or terminate death benefits payments. 1. Deceased Employee's Name (Last, First, Middle Initial) 4. Date of Death 2. Insurer Claim Number 3. Date of Injury 5. Social Security Number 7. Date of Birth 6. Place of Death 8. Employer 10. Address City State Zip Code Telephone 9. Insurer 11. Address City State Zip Code Telephone 12. WIDOW(ER) AND/OR CHILDREN: a. Name (Last, First Middle Initial) Address b. Name (Last, First Middle Initial) Address c. Name (Last, First Middle Initial) Address d. Name (Last, First Middle Initial) Address e. Name (Last, First Middle Initial) Address Date of Birth City Date of Birth City Date of Birth City Date of Birth City Date of Birth City Weekly Rate State Weekly Rate State Weekly Rate State Weekly Rate State Weekly Rate State Date Benefits Terminated Zip Code Date Benefits Terminated Zip Code Date Benefits Terminated Zip Code Date Benefits Terminated Zip Code Date Benefits Terminated Zip Code 13. DEPENDENT PARENTS, GRANDCHILDREN, BROTHER(S) AND/OR SISTER(S): a. Name (Last, First Middle Initial) Address b. Name (Last, First Middle Initial) Address c. Name (Last, First Middle Initial) Address Date of Birth City Date of Birth City Date of Birth City Weekly Rate State Weekly Rate State Weekly Rate State Date Benefits Terminated Zip Code Date Benefits Terminated Zip Code Date Benefits Terminated Zip Code This is to certify that the original Death Benefits Report and the Compensation Report (Form 07-6104) have been mailed to all dependents at the above address(es), and copies have been mailed to the Alaska Workers' Compensation Board. 14. Name and Title of Person Submitting Report (Print or Type) 17. Address Form 07-6118 (Rev 04/2010) 15. Signature City State Zip Code 16. Report Date Telephone American LegalNet, Inc. www.FormsWorkFlow.com