Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 Illinois National Guardsmen’s and Naval Militiamen’s Compensation Act Form Pursuant to provisions of the Illinois National Guardsmen’s and Navel Militiamen’s Compensation Act, application is hereby made for payment of benefits to the death of: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Name of Illinois National Guard or Navy Militia Member: _____________________________________________________ Address at Death: ___________________________________________________________________________________________ Date of Death: ______________________________________________________________________________________________ Date of Injury Resulting in Death: ___________________________________________________________________________ Unit Address: ______________________________________________________________________________________________ ____________________________________________________________________________________________________________ Rank and assignment in which decedent was serving at time of death or at time of injury resulting in death: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Social Security Number: ____________________________________________________________________________________ Name(s), Address(es) and Social Security Numbers of all beneficiaries designated by decedent for receipt of benefits. Name Address Social Security Number $ amount or % share ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ (If no beneficiary designation) Name and Address of personal representative of decedent’s estate (administrator, executor), Date of Appointment, Court Appointing and Probate File Number: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ (If no beneficiary designation) Names and Addresses of decedent’s heirs or next-of-kin: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Statement of circumstances resulting in or the events causing the death of the Illinois National Guard or Navy Militia Member (newspaper accounts, death certificate, coroner’s certificate or other documentation may be attached, if available): ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ (If more space is needed, please attach additional sheets.) Printed by authority of the State of Illinois - March 2005 - 500 - CC-89 American LegalNet, Inc. www.USCourtForms.com