CHECK APPROPRIATE BOX: SPOUSE PARENTS SPOUSE WITH DEPENDENT CHILDREN OTHER DEPENDENTS DEPENDENT CHILDREN BURIAL EXPENSE ONLY (Must be filed by guardian) INFORMATION REGARDING DECEASED:1. Name of Deceased: 2.Date of Birth: Soc. Sec. # *:Date of Death: 3.Date of Injury: (If different from date of death):4.Deceased222s Address:5.Employer at time of death:Employer222s address:6.Briefly state cause ofdeath:7.List name and address of health care providers that treated deceased in the last two years and state condition treated: Date of Birth: Yes No If yes, state details Your Address:Date of Marriage to Deceased:Place of Marriage:Were You or Deceased Married Previously? CLAIM FOR SPOUSAL BENEFITS: (Provide arriage certificate) 1.Your Name:Name: American LegalNet, Inc. www.FormsWorkFlow.com 5. Did you reside with deceased at time of death? Yes No If living apart provide reason, such as divorced, divorce pending, annulment, abandonment. CLAIM FOR DEPENDENT CHILDREN: (Provide birth certificates) 1.List dependent children: NAME DATE OF BIRTH RELATIONSHIP TO DECEASED ADDRESS AT TIME OF DEATH 2.Which of these children are still in your care and custody? 3 Is a posthumous (unborn) child expected? Yes No If yes provide anticipated date of delivery: OTHER DEPENDENTS: 1.Name:2.Address:3.Relationship to Deceased: 4. Extent of Dependency: Full Partial Please give details: D To be filed at either office of the Industrial Commission: Phoenix Industrial Commission of Arizona Tucson Industrial Commission of Arizona Office: 800 W. Washington Street Office: 2675 E. Broadway Phoenix, Arizona 85007-2922 Tucson, Arizona 85716-5342 P. O. Box 19070 Phoenix, Arizona 85005-9070 * The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commission222s forms, prescribed under the Commission222s Rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by the social security number. THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CONTACT SPECIAL SERVICES AT (602) 542-1829. American LegalNet, Inc. www.FormsWorkFlow.com