Date Employee Dependent Address City, State, Zip Deceased Employee Date of Injury Claims Administrator Address City, State, Zip Telephone Number Employer Claim Number NOTICE REGARDING WORKERS' COMPENSATION DEPENDENCY BENEFITS (Claims Administrator's Name) is handling the workers' compensation dependency claim on behalf of (Employer). This notice is to advise you of the status of dependency benefits for the workers' compensation injury of . A copy of this and all notices will be sent to all claimants. Only the items completed below concern the benefits at this time. Payments are beginning being resumed for the period from through . The first payment is enclosed sent separately. Benefits vary according to the number of dependents and the degree of dependency. These benefits have been calculated as follows: . Payments will be sent to you every two weeks on and will continue until . You may also be entitled to reimbursement of up to $ for burial expenses. You are entitled to any benefits which were due and payable to (deceased employee) before (his/her) death. (He/She) was entitled to . These benefits are enclosed I am not able to determine whether benefits are due at this time because . In order to make a decision, I need . I expect to make a decision on or before sent separately. . I will contact you at that time. Prior to the death of (deceased employee) , benefits had accrued, but were not paid. Based on available information, I am unable to determine if you are eligible for these benefits. To reach a decision, I need I expect to make a decision on or before . I will contact you at that time. Payments are ending because Benefits paid to you total $ at $ and were paid from per week. Please see the attached for (additional) periods paid. Additionally, we paid $ for Included in this amount is an overpayment totalling $ is being asserted against through . . Credit for the overpayment . The State of California requires that you be given the following information: If you disagree with the decision, you may consult with a State Information and Assistance Officer at 1-800-736-7401 or call your local Information and Assistance Officer at . You may also consult with and be represented by an attorney, and/or apply to have your case heard by the Workers' Compensation Appeals Board. If you have questions, call me at . Sincerely, , Claims Examiner Enc.: cc: DWC 500-G Benefits Pamphlet Applicant's Attorney Employee Claim Form Payment Record 3/96 2002 © American LegalNet, Inc.