FORM 18 Agreement No. ____________ INDUSTRIAL ACCIDENT BOARD State of Delaware AGREEMENT FOR COMPENSATION FOR DEATH (Memorandum of this Agreement must be filed with the Board) (SECTION 107) We the undersigned, being all the dependents who are entitled to compensation on account of the death of ___________________________________________________________________________________________ from a personal injury sustained by him or her by an accident arising out of and in the course of his or her employment and _____________________________________________________________________________ in whose service the said _______________________________________________________________________ was employed at the time of said injury, have reached an agreement in regard to the compensation to be paid by said employer. Date of accident ______________________________________________________________________________ Place of accident _____________________________________________________________________________ Cause of injury ______________________________________________________________________________ Nature of injury ______________________________________________________________________________ Date of Death _______________________________________________________________________________ The terms of the agreement under the above facts are as follows: That the compensation payable shall be at the rate of $_______________ per week, based upon an average weekly wage of $_______________ at the time of said injury and shall be paid from the ___________ day of ______________, 20____, until terminated, to the following person, or persons, or their legal representative, in accordance with the provisions of the “Delaware Workmen’s Compensation Law of 1917,” as amended and in the amount herein designated. _________________________________________ $____________________ per week _________________________________________ $____________________ per week _________________________________________ $____________________ per week _________________________________________ $____________________ per week _________________________________________ $____________________ per week Dated this _____________day of __________________, 20_____. Witness: ______________________________________________ ______________________________________________ ______________________________________________ _______________________________________ ______________________________________________ ______________________________________________ ______________________________________________ _______________________________________ Signature of Dependents ______________________________________________ Signature of Employer By ____________________________________________ Authorized Agent American LegalNet, Inc. www.FormsWorkflow.com