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Claim For Compensation For Line Of Duty Compensation Benefits Form. This is a Missouri form and can be use in Workers Comp.
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Tags: Claim For Compensation For Line Of Duty Compensation Benefits, WCLoD-1, Missouri Workers Comp,
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
CLAIM FOR COMPENSATION FOR
LINE OF DUTY COMPENSATION BENEFITS
Instructions:
1. Type or print clearly in ink.
2. Claim must be filed by the estate of the deceased.
3. Last page of this form must be signed by claimant and notarized.
4. If question is not applicable, please answer with N/A.
5. Claim may be filed in person at any of the Division’s adjudication offices or
by mail at the address indicated above.
6. Claim must be filed within one year of the date of death of a law enforcement
officer, emergency medical technician, air ambulance pilot, air ambulance
registered professional nurse, or firefighter killed in the line of duty.
3315 West Truman Blvd.
P.O. Box 58
Jefferson City, MO 65102-0058
573-526-4941
www.labor.mo.gov/DWC
FOR DIVISION USE ONLY
Case Number: _____________________
Date Received: ____________________
Pursuant to the provisions of the Line of Duty Compensation Act, §287.243, RSMo, as amended, application is
hereby made for payment of benefits as follows:
1. Decedent’s Name
2. Decedent’s Social Security Number
3. Address of decedent’s Missouri residence at time of death
If no Missouri address, please provide the address of decedent’s
residence at time of death
4. Date of death
6. Employer’s name and address
5. Date of injury resulting in death
7. Place of injury causing death
8. Rank and title of position or designation of the position in which decedent was serving at time of death, or at time of injury resulting in death
9. Name and address of Personal Representative
10. County where the estate is being probated
11. County which has jurisdiction to probate the estate
12. Decedent’s marital status at time of death
13. (If applicable) name, address, phone number and Social Security Number (last four digits) of
decedent’s surviving spouse
14. Did decedent have children?
Yes
No
15. Please attach copies of the following documents (if
available) that provide a full, factual account of the
circumstances resulting in or the course of events causing
the decedent’s death:
A.
B.
C.
D.
E.
F.
Report of Casualty or Accident filed with the employer;
Certificate of Death;
Police Report;
Autopsy Report;
Medical Records;
Toxicology Report.
16. Please attach copies of the following documents that support this application:
A. Certified copy of the Order granting Refusal of Letters to surviving
spouse or unmarried minor, minor, or dependent children entered by the
Circuit Court;
B. Certified copy of the Circuit Court Order on the Determination of
Heirship;
C. Certified copy of the Circuit Court Order on small estate procedures;
D. Certified copy of the Circuit Court Order on Termination of
Administration and approval of the final settlement of the estate;
E. Court’s Decree of Final Distribution.
17. Please attach copies of any other documents that may be relevant or useful in consideration of this claim.
WCLoD-1 (03-12) AI
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Claimant Information
1. Claimant’s Name
2. Claimant’s Address
3. Telephone Number
Home:
Work:
4. Relationship to decedent
5. Date of filing claim
6. A Petition for Issuance of Letters of Administration was filed In the Circuit Court of
County, Probate Division,
Estate Number:
7. A full probate administration was not required based upon the following:
A. Refusal of Letters to surviving spouse or unmarried minor, minor, or dependent children ordered by the Circuit Court;
B. Determination of Heirship in an intestate case.
8. Name and address of the attorney representing the estate
STATE OF______________________________
COUNTY OF____________________________
9. (please check the appropriate box below)
I
am
am not currently represented by an attorney.
I agree to notify the Division in writing if and when I hire an attorney to
represent me in this case.
)
)
)
_______________________________________ on oath, states that the information in the foregoing application was
completed by, or at the direction of, the undersigned and that matters stated therein are true and correct.
__________________________________________
Claimant’s Signature
Subscribed and sworn to before me this
__________ day of_________________, 2______.
Notary Seal
_________________________________________
Notary Public
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