State of New York - Workers’ Compensation Board INSTRUCTIONS FOR COMPLETING AFFIDAVIT FOR DEATH BENEFITS WHERE THERE IS NO SURVIVING SPOUSE OR DEPENDENT CHILDREN FOR DEPENDENT PARENTS OR DEPENDENT GRANDPARENTS 1. This affidavit is to be completed by the person seeking death benefits under the Workers’ Compensation Law. 2. Complete the 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 of two possible words or phrases; please fill in the blank with one of the choices if the paragraph is applicable to your situation. Please include the WCB Case Number, if you know it, on page 2. 5. After completing this affidavit, read it to insure that 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 Mailing 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 selfinsurer, 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-3 (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 the 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). AFF-3 (8-09) Decedent’s SS#____________________ -2- American LegalNet, Inc. www.FormsWorkFlow.com 6. The Decedent’s gross wages or salary for the employment listed above was $_______________________ (amount), and it was paid ___________________ (weekly, biweekly, monthly, bimonthly). 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 engaged in 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 that 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 dependent child(ren): (a) any dependent parent of the Decedent, and (b) any dependent grandparent of the Decedent. The parent or grandparent must have been dependent upon the Decedent at the time of the Decedent’s death. Parent(s) or grandparent(s) found to be dependent is/are entitled to a portion of the Decedent’s death benefit, as are any dependent grandchild(ren), brother(s) or sister(s)). 9. I am the (please check the appropriate box): Dependent father; Dependent mother; Dependent grandfather; Dependent grandmother; Legal representative. If you are the legal representative of the dependent parent or grandparent, please state the name and address of the dependent parent or grandparent and their relationship to the decedent: ________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Please attach documentation to establish the relationship between the dependent parent or grandparent and the Decedent. If applicable, please attach documentation such as court order or power of attorney demonstrating that you are the legal representative of the dependent parent or grandparent. 10. The dependent ________________________________ (father, mother, grandmother, grandfather) (did or did not) _________________live with the Decedent at the time of his/her death. AFF-3 (8-09) Decedent’s SS#____________________ -3- American LegalNet, Inc. www.FormsWorkFlow.com 11. The dependent ______________________________ (father, mother grandmother, grandfather) was (partly or wholly) _____________________dependent on the decedent because __________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ (explain how the parent or grandparent was dependent on the Decedent) Please attach documentation, such as tax returns, filed by the Decedent and the dependent parent or grandparent, checks from the Decedent, bank statements, or other documentation, showing that the Decedent supported these dependents. 12. The dependent parent or grandparent had at the Decedent’s death, and currently has, the following sources of income: _______________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ (list all sources of income the dependent parent or grandparent receives, including but not limited to employment, Social Security, pension, IRA, support form other child or grandchild, as well as the amount received and how often it is received) 13. The dependent parent or grandparent has the following expenses per month: __________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ (list all expenses the dependent has per month and the amount of each expense) 14. The Decedent __________________ (did or did not) pay some of the expenses of the dependent parent(s) or grandparent(s) directly. If the Decedent did pay some of the dependent parent’s or grandparent’s expenses directly, list the expense, who was legally responsible for the expense, the amount of the expense, and how the Decedent paid the expense.____________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Please attach documentation showing the expenses incurred by the dependent parent(s) or grandparent(s) and documentation indicating whether the expenses were paid by the Decedent or some other person. (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.) AFF-3 (8-09) Decedent’s SS#____________________ -4- American LegalNet, Inc. www.FormsWorkFlow.com 15. I have paid $_________________ in funeral expenses for the Decedent and request reimbursement from the employer and/or carrier. Please attach copies of 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 a 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.) 17. 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 proof of relationship legal representative documentation documentation showing support of dependent parent or grandparent AFF-3 (8-09) Decedent’s SS#____________________ -5- American LegalNet, Inc. www.FormsWorkFlow.com