State of New York – Workers’ Compensation Board INSTRUCTIONS FOR COMPLETING AFFIDAVIT FOR DEATH BENEFITS WHERE THERE IS NO SURVIVING SPOUSE OR DEPENDENT CHILD(REN) FOR DEPENDENT BROTHER(S), DEPENDENT SISTER(S) OR DEPENDENT GRANDCHILD(REN) 1. This affidavit is to be completed by the person seeking death benefits under the Workers’ Compensation Law. 2. Complete this affidavit so it truthfully and accurately reflects the facts of your situation. Please strike out all paragraphs that are not applicable. 3. Please print legibly. Please include the Decedent’s Social Security number on each page. 4. Please fill in the blanks as specifically as possible. In most cases we have provided a choice from two possible words or phrases, please fill in the blank with one of those choices if the paragraph is applicable to your situation. Please include the WCB Case Number on page 2, if you know it. 5. After completing the affidavit, read it to ensure it is truthful and accurate and swear to your truthfulness before a notary public. 6. Once you have completed the form and had it notarized, submit the original to the Workers’ Compensation Board District Office or Downstate Central Mail Center as appropriate: Albany 12241-100 Broadway Menands. (866) 750-5157. For all accidents in the counties of: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton, Green, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schohaire, Ulster, Warren, Washington. Binghamton 13901- State Office Building, 44 Hawley Street. (866) 802-3604. For all accidents in the counties of: Broome, Chemung, Chenango, Cortland, Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins. Buffalo 14202- 369 Franklin Street. (866) 211-0645. For all accidents in the counties of: Cattaraugus, Chautauqua, Erie, Niagara Rochester 14614 – 130 Main Street West. (866) 211-0644. For all accidents in the counties of: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Steuben, Wayne, Wyoming, Yates. Syracuse 13203 – 935 James Street (866) 802-3730. For all accidents in the counties of: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence. Downstate Centralized Mailing (for New York City, Hempstead, Hauppauge and Peekskill district offices) – PO Box 5205 Binghamton, NY 13902-5205. NYC (800) 877-1373, Hemp. (866) 805-3630, Haup. (866) 681-5354, Peek. (866) 746-0552. For all accidents in the counties of: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester. 7. Please be advised that any person who knowingly and with intent to defraud presents, causes to be presented, or prepares with knowledge or belief that it will be presented to, or by an insurer, or self insurer, any information containing any false material statement or conceals any material fact shall be guilty of a crime and subject to substantial fines and imprisonment. AFF-2 (8-09) Decedent’s SS#________________ -1- American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT FOR DEATH BENEFITS In the Matter of the Claim of _____________________________, Claimant, (Your first and last name) Regarding the death of ______________________, Decedent AFFIDAVIT (Decedent’s first and last name) v. WCB Case# _____________ WCL § 16 _______________________________________, Employer (Name of Decedent’s Employer at the time of death) **************************** State of __________________________) (State where you have this notarized) ) ss: County of_________________________) (County where you have this notarized) I, being duly sworn, do hereby depose and say: 1. I am the above-captioned Claimant, and I reside at _______________________________________ ________________________________________________________________(street, city, state). My telephone number is ______________________(area code, number). My Social Security Number is ____________________ and the Decedent’s Social Security Number is ____________. 2. The Decedent (does or does not) __________________________ have an established Workers’ Compensation injury claim. The claim number is WCB# _________________. This death claim (is or is not) ______________ based on the established injury claim. 3. The Decedent’s date of birth is ______________________ (month, date, year). 4. On ____________________(date of death), the above captioned Decedent, (was or was not) __________________ employed by above-captioned Employer located at ____________________ _______________________________________________________________,( street, city, state). 5. On ____________________ (date and time of death), the Decedent was located on ____________ ___________________________(street, city and state) and was engaged in the activities of ____________________________________________ (what was the Decedent doing at the time of death) and died as a result of ________________________________________________________ _____________________________________________________(explain how the Decedent died). 6. The Decedent’s gross wages or salary for the employment listed above was $_________________ (amount), and it was paid ______________________(weekly, biweekly, monthly, bimonthly). AFF-2 (8-09) Decedent’s SS#________________ -2- American LegalNet, Inc. www.FormsWorkFlow.com 7. The Decedent (had or did not have) ___________________ other employment at the time of death other than the employment listed above. The Decedent’s other employer was _______________________________ and is located at __________________________________ (street, city and state). The gross wages or salary earned for this employment was $__________________________ (amount), and it was paid _________________________ (weekly, biweekly, monthly, bimonthly). Please attach copies of documents by which the Board can determine the Decedent’s total gross weekly earnings for all employment for the period of one year prior to death; for example, the Decedent’s pay stubs for this period or the Decedent’s W-2 for this period. If all of these documents are not available, then attach any pay stubs for this period and/or the W-2 for this period. 8. I affirm at the time of the Decedent’s death, the Decedent did not have a surviving spouse, any child(ren) under the age of 18 or under the age of 23, enrolled and attending an accredited educational institution as a full time student, or any dependent child(ren) who were totally blind or totally and permanently disabled. Please attach a death certificate, if available. (Please note: the Workers’ Compensation Law provides death benefits for the following if there is no surviving spouse or child(ren): (a) any dependent grandchild(ren) or brother(s) or sister(s) under the age of 18, and (b) any dependent grandchild(ren) or brother(s) or sister(s) under the age of 23, enrolled and attending an accredited educational institution as a full time student provided that full time attendance is certified by such institution, and (c) any dependent children who are totally blind and totally or permanently disabled.) 9. I am the __________________________________ (father, mother, legal guardian) of the following dependent grandchild(ren) or dependent brother(s) or sister(s) of the Decedent: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ (first and last names) (relationship to Decedent) (date of birth) Please attach the birth certificate for all dependent grandchild(ren) and dependent brother(s) or sister(s). If the dependent grandchild(ren), brother(s) and/or sister(s) were adopted by the Decedent’s child(ren) or parent(s), then please attach court orders of adoption if a birth certificate is not available. If you are other than the parent, please attach legal documents that establish that you are the legal guardian of any dependent grandchild(ren) or dependent brother(s) or dependent sister(s). 10. The dependent ____________________________________ (grandchild(ren), brother(s), sister(s)) __________________ (did or did not) live with the Decedent at the time of his or her death. 11. Prior to the Decedent’s death the dependent grandchild(ren), brother(s) or sister(s) lived at: ______________________________________________________________________________ ______________________________________________________________________________ AFF-2 (8-09) Decedent’s SS#________________ -3- American LegalNet, Inc. www.FormsWorkFlow.com ______________________________________________________________________________ (street) (city) (state) 12. The dependent __________________________ (grandchild(ren), brother(s) or sister(s)) were dependent on the Decedent because __________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ (explain how the dependent grandchild(ren), brother(s) or sister(s) were dependent on the Decedent) Please attach documentation, such as tax returns, checks from the Decedent, bank statements, or other documentation showing that the Decedent supported these dependents. 13. I request that I be designated as the legally responsible person in order to receive the benefits payable on behalf of the dependent grandchild(ren), brother(s) or sister(s) listed above. 14. If so designated as the person legally responsible for the above dependent grandchild(ren), brother(s) or sister(s), I agree to file reports, annually or more frequently as required by the Chairman of the Workers’ Compensation Board, in relation to any expenditure of any minor beneficiary’s awards. (Please note: the Workers’ Compensation Law provides funeral benefits up to a maximum of $6,000 in the counties of Bronx, Kings, Nassau, New York, Queens, Richmond, Rockland, Suffolk, and Westchester and up to $5,000 in all other counties.) 15. I have paid $___________________________ in funeral expenses for the Decedent and request reimbursement from the employer and/or carrier. Please attach copies of receipts or other documents pertaining to the payment of funeral expenses. 16. In relation to the death of the Decedent, I (check one or strike out all three if none applies): am planning to pursue a wrongful death action against ______________________________. have commenced a wrongful death action against __________________________________. have settled my wrongful death action against _____________________________________ for the sum of $________________________________. Please attach copies of the carrier’s consent to settle the wrongful death action and the closing statement (if available). (Please note: If you receive a sum of money as the result of a wrongful death action, the Workers’ Compensation Law allows the carrier to have a lien or credit against that money recovery. The carrier’s lien and credit rights may affect your ability to receive workers’ compensation benefits for a period of time until the lien and/or credit is exhausted. It is important to advise the carrier of the status of any wrongful death action and to obtain its consent prior to any settlement.) AFF-2 (8-09) Decedent’s SS#________________ -4- American LegalNet, Inc. www.FormsWorkFlow.com 17. That by signing my name below, I hereby affirm the statements made herein are true, and I make this affidavit under the penalties of perjury. I further affirm that I understand that the law prescribes penalties for perjury and for willfully making false statements in connection with an insurance claim. ______________________________________ (first and last name ) Sworn to before me this _____________ Day of __________________, 20______ ________________________________________ Notary Public Please check the appropriate boxes designating enclosed documents: payroll information death certificate birth certificate(s) order(s) of adoption documentation showing support of dependent grandchildren, brothers or sisters certified enrollment at a college proof of relationship legal guardian documentation AFF-2 (8-09) Decedent’s SS#________________ -5- American LegalNet, Inc. www.FormsWorkFlow.com