Agreement To Compensation Between The Dependents Of Deceased Employee And Employer
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Agreement To Compensation Between The Dependents Of Deceased Employee And Employer Form. This is a Indiana form and can be use in General Workers Compensation.
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Tags: Agreement To Compensation Between The Dependents Of Deceased Employee And Employer, 18875, Indiana Workers Compensation, General
AGREEMENT TO COMPENSATION BETWEEN THE
DEPENDENTS OF DECEASED EMPLOYEE AND EMPLOYER
INDIANA WORKER'S COMPENSATION BOARD
402 West Washington Street, Room W196
Indianapolis, IN 46204-2753
State Form 18875 (R2 / 5-10)
Privacy Notice: This agency is requesting disclosure of employees Social Security number in accordance with I.C. 22-3-4-13.
Federal Identification number
Social Security number
Board number
Name of Employer
Name of Employee
Date of injury / illness (month, day, year)
Date of death (month, day, year)
AGREEMENT STATEMENT
We, the undersigned being all the dependents of the deceased employee who are entitled to compensation under the provisions of the Indiana Workers
Compensation / Occupational Diseases Act due to the death of this employee resulting from an injury / illness arising out of a and in the course of their
employment and said employer, have reached an agreement in regard to compensation.
The terms of this agreement are:
That the employer shall pay to the following dependents, in equal shares, a weekly compensation of
$____________________, based on an average weekly wage of $__________________________,
beginning on the ______ day of ________________________________, 20______, and to continue
during the dependency of any one of them, not exceeding, in the aggregate, five hundred (500) weeks.
The employer shall also pay the reasonable and necessary medical expenses incurred as a result of the
injury / illness together with the statutory burial expenses of $____________________ of said employee.
DEPENDENTS OF DECEASED EMPLOYEE
NAME
AGE
RELATIONSHIP
WHOLLY OR PARTIALLY
DEPENDENT
ADDRESS
(number and street, city, state, and ZIP code)
Remarks:
Signature of dependent
Date signed (month, day, year)
Signature of parent / guardian for dependent
Date signed (month, day, year)
Signature of employer
Date signed (month, day, year)
Signature of insurance company adjustor / representative
Date signed (month, day, year)
(For board use only)
E-mail address of insurance company adjustor / representative Telephone number of insurance company adjustor / representative
(
)
Name of insurance company
Address of insurance company (number and street, city, state, ZIP code)
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