NYS Workers' Compensation Board Affidavit for Death Benefits How to Complete This Affidavit for Workers' Compensation Death Benefits 1. The law provides up to $12,500 for funeral expenses downstate, and $10,500 upstate, depending on the county where the expenses are incurred. 2. The law also provides weekly benefits up to a maximum amount, based on the date of accident, for the following: (a) the legal surviving spouse until the spouse remarries, (b) Decedent's children up to age 18 (age 23 if they are attending an accredited educational institution as a full-time student), and (c) any dependent children of any age who are totally blind or totally and permanently disabled. 3. If there is no legal surviving spouse or dependent children, the law provides weekly benefits to grandchildren or siblings under age 18 who were dependent upon Decedent for support; or to parents or grandparents who were dependent upon Decedent for support when Decedent died. 4. If there are no individuals entitled to weekly death benefits, then $50,000 may be paid to Decedent's parents, or to Decedent's estate if Decedent's parents are deceased. 5. If you receive money as a result of a wrongful death action, the law allows the insurer to have a lien or credit against that money. The insurer's lien and credit rights may affect your ability to receive workers' compensation benefits until the lien and/or credit is exhausted. It is important to advise the insurer of the status of a wrongful death action, and to obtain its consent prior to settlement. Workers' Compensation Death Benefits 1. The person seeking workers' compensation death benefits should complete this affidavit. All claimants must complete Section A, Section B, and Section 1. Based on your relationship to the decedent, you must also complete the following sections: Spouses: Sec. 2 (and Sec. 3 if there are children). Parents or Guardians for Children: Sec. 3. Dependent Parents, Grandparents: Sec. 4. Dependent Grandchildren, Siblings: Sec. 5. Non-dependent Parents: Sec. 6. Legal Representative of Decedent's Estate: Sec. 7. 2. You only need to complete the sections listed above that pertain to your relationship with the Decedent. Strike out all sections or paragraphs that do not apply to you with an X. 3. Print legibly. Include decedent's Social Security number on each page, and the WCB Case Number on page 3, if you know it. 4. Answer as specifically as possible. Reread this affidavit after completion to ensure it is accurate because you are swearing to its truthfulness. Workers' compensation fraud is a felony punishable by fines and imprisonment. 5. Notarize this affidavit. Mail the completed and notarized affidavit, and all attachments, to the Workers' Compensation Board at the address listed below. For questions, call the Office of the Advocate for Injured Workers: 1-800-580-6665. NYS Workers' Compensation Board Centralized Mailing PO Box 5205 Binghamton, NY 13902-5205 American LegalNet, Inc. www.FormsWorkFlow.com NYS Workers' Compensation Board Affidavit for Death Benefits All applicants must complete this page and have this document notarized on the final page, Section B. Mail this affidavit and all attachments to the Workers' Compensation Board. In the Matter of the Claim of ___________________________________________, Claimant (Your first and last name) Section A: All Applicants Regarding the death of ___________________________________________, Decedent (Decedent's first and last name) AFFIDAVIT WCB # _________________ WCL § 16 v. ___________________________________________, Employer (Name of Decedent's Employer at the time of Death) ______________________________________________________________________________ (Address of Employer) State of ________________________________________ (State where you have this notarized) County of ______________________________________ (County where you have this notarized) I, being duly sworn, do hereby depose and say (answer following sections, as appropriate): Decedent's Social Security Number: ________________________________ AFF-1 (6-16) Page 1 of 10 American LegalNet, Inc. www.FormsWorkFlow.com NYS Workers' Compensation Board Affidavit for Death Benefits All applicants must complete this section. Attach the following if applicable. Check the box if included. ___ Death certificate (required). ___ ___ ___ Copies of documents the Board can use to determine the Decedent's total gross weekly earnings for all employment for one year prior to death (pay stubs, W-2 form, etc.). Copies of receipts or other documents pertaining to the payment of funeral expenses. Copy of the insurer's consent to settle a wrongful death action. Section 1: All Applicants 1. I am the claimant. I live at ______________________________________________________________. (street, city, state, zip code) My telephone number is _____________________________. (area code, number) My Social Security number is _____________________________________________________________. (all nine digits) I am the ________________________________________________________ of the Decedent. (spouse, son, daughter, parent, grandparent, brother, sister, grandchild, estate representative) 2. The address of the employer named above is ______________________________________________. (street, city, state, zip code) 3. The Decedent's date of birth is _________________________________________________ . (month, day, and year) The Decedent's Social Security number is __________________________________________ . (all nine digits) The Decedent's date of death is ___________________________________________________________. (month, day, and year) On the date of death, the Decedent _______________ employed by the employer named above. (was or was not) On _________________, the Decedent was at _______________________________________________ (date and time of death) (street, city, and state) and was engaged in ____________________________________________________________________ (what Decedent was doing at the time of death) and died as a result of ___________________________________________________________________. (explain how Decedent died). 4. The Decedent's gross wages (including overtime and tips) for this employment was $_______________, (amount) and also $____________ for ________________________, paid on a _____________________ basis. (amount) (housing, rent, meals, etc.) (weekly, biweekly, etc.) 5. The Decedent _______________________________ other employment at the tim