PETITION TO DETERMINE COMPENSATION DUE TO DEPENDENTS OF DECEASED EMPLOYEE To the Industrial Accident Board of the State of Delaware Sitting in and for County Claimant (Deceased Employee) vs. Claimant SS# Date of Birth Insurance Carrier Employer Case File No. The undersigned petitioner respectfully represents: That the above named claimant and the above named employer have failed to reach an agreement in regards to compensation due said claimant as the dependent of a deceased employee of said employer. The undersigned therefore prays that your Honorable Board shall, after due notice of the time and place of hearing served on all parties in interest, hear and determine the matter in accordance with the facts and the law and state its conclusions of fact and rulings of law. Dated this day of A.D. 20 .Witness: Name: Signature Signature Print Name Print Name Document Control #: B60-07-12-12-11 } American LegalNet, Inc. www.FormsWorkFlow.com INDUSTRIAL ACCIDENT BOARD STATE OF DELAWARE Statement of Facts Upon Failure to Reach an Agreement 1. Name of Employee Address City State Zip Telephone Number E-mail (optional) 2. Date of Accident 3. Place of Accident 4. Name of Employer Employer Contact Name E-mail (optional) Address City State Zip Telephone Number Fax # 5. Name of Insurance Carrier / 3rd Party Administrator 6. Occupation of employee at the time of accident 7. Nature of accident and how it happened 8. Describe the nature of injury 9. Did employee receive medical, surgical or hospital service? Yes No 10. When was notice of injury given to or received by employer? 11. Give names and addresses of all employers for the last 5 years. If more space is needed, attach a separate sheet. NAME: ADDRESS: 12. State weekly wage when injured 13. State names and addresses of all treating doctors for this claim. If more space is needed, attach a separate sheet. NAME: ADDRESS: American LegalNet, Inc. www.FormsWorkFlow.com 14.State number of weeks employed during the last twelve months 15.State at what trade or occupation employed during the last twelve months 16.Date of death 17.What were the expenses of last sickness and burial 18.Amount of these expenses paid by the employer 19.Name of widow or widower of deceased, if dependent 20.Names and dates of birth of dependent children under sixteen years of age.21.Names and addresses of surviving father and mother of deceased, if dependent.22.Give names and dates of birth of dependent sibling(s) of deceased under sixteen years ofage.23.State any other important facts bearing on the case above presented. American LegalNet, Inc. www.FormsWorkFlow.com