Form F - Fatality October 2016 Edition KENTUCKY DEPARTMENT OF WORKERS222 CLAIMS 657 CHAMBERLIN AVENUE, FRANKFORT, KY40601 Workers222 Compensation Claim No. IF THIS FORM IS NOT PROPERLY COMPLETED, IT WILL BE RETURNED. Every section should be completed. If a section is not applicable, fill in the blank with N/A Decedant There are no known dependents DEPENDENTS Name Address Date of Birth Relationship to Decedent Dependent or Decedent at Time of Accident? Living with Decedent at Time of Accident? Attach the following if applicable: 1. Marriage License 2. Birth Certificate or proof of adoption 3. Court order or proof of guardianship or dependency OTHER INFORMATION If additional information is pertinent to settlement, explain: This the day of ,20 . Attorney (Signature) Claimant (signature) American LegalNet, Inc. www.FormsWorkFlow.com