State of New York - Workers' Compensation Board CLAIM FOR COMPENSATION IN A DEATH CASE This claim will be processed more quickly if copies of necessary documents are submitted to the Board. Attach copies of the documents which you have in your possession. Otherwise obtain copies and bring them to the first hearing. DO NOT DELAY filing this claim form. Necessary documents are as follows: a. A medical report from doctor who treated the deceased. b. Death certificate. c. Proof of relationship such as birth certificate, marriage certificate, adoption papers, etc. d. Itemized funeral bill. W.C.B. CASE NO.(if known) CARRIER CASE NO. CARRIER CODE NO. DECEDENT'S SOC. SEC. NO. CLAIMANT'S SOC. SEC. NO. DATE OF ACCIDENT NAME DECEASED EMPLOYER CARRIER CLAIMANT ADDRESS (Give No, Street,City, State and Zip Code) Apt. No. Apt. No. I hereby make claim under the Workers' Compensation Law for compensation arising out of the death of the deceased named above as the result of injury sustained in the employ of the above named employer, and, in support of this claim submit the following information: 1. a. Death occurred on ................................................................ day of ................................................................. , ........................................ at ..................................................................................................................................................... (Attach death certificate, if available). b. How did accident or occupational disease happen? (Describe fully, stating whether the injured person fell, was struck, etc. and what factors or events led up to or contributed to the accident.) ................................................................................................................................................................................................................ ................................................................................................................................................................................................................ ................................................................................................................................................................................................................ c. Place of Accident: ....................................................................................................................................................................................... d. Nature of injury and part(s) of body injured: ............................................................................................................................................... Note: Attach a medical report, if available. Name 2. ATTENDING PHYSICIAN LAST PHYSICIAN OR HOSPITAL UNDERTAKER PERSON WHO PAID UNDERTAKER BILLS Address 3. 4. 5. 6. Amount of Undertaker's Bills $__________________ Amount paid, if any $________________________ (Attach funeral bill, if available.) 7. Claimant's date of birth ____________________________ 8. Relationship to deceased _______________________________________ 9. Is deceased survived by a spouse and/or children under 18 years of age or under 23 years of age and enrolled and attending as full-time students in any accredited educational institution? No Yes 10. Survivors or dependents of the deceased: (See reverse side for instructions) NAME ADDRESS BIRTH DATE RELATIONSHIP (Attach proof of relationship such as birth certificate, marriage certificate, adoption papers, etc., if available) (SEE INSTRUCTIONS ON REVERSE SIDE) IF YOU HAVE ANY QUESTIONS ABOUT CLAIMING DEATH BENEFITS, CONTACT THE NEAREST OFFICE OF THE WORKERS' COMPENSATION BOARD. SI TIENE ALGUNAS PREGUNTAS RESPECTO A COMO RECLAMAR BENEFICIOS POR MUERTE, COMUNIQUESE CON LA OFICINA MAS CERCANA DE LA JUNTA DE COMPENSACION OBRERA C-62 (1-11) THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE W ITH DISABILITIES WITHOUT DISCRIMINATION. American LegalNet, Inc. www.FormsWorkFlow.com 11. IF YOU ARE THE SPOUSE OR CHILD OF THE DECEASED ENTER THE FOLLOWING INFORMATION AS APPLICABLE: a. You were married to the deceased on _______________________day of ____________________________,________________ at _________________________________ by ___________________________________ (Attach marriage certificate, if available). (Place) Person Performing Ceremony b. Number of children under 18 years of age at the time of the death of the deceased. _________________ c. Number of children at least 18 years of age but under 23, enrolled and attending as full time students in any accredited educational institution at the time of the death of the deceased._______________ 12. IF YOU ARE THE SPOUSE OF THE DECEASED, indicate your share of survivor's insurance benefits, if any, being received under the Social Security Act. $_____________ (If available, attach copy of Social Security Award certificate showing your share of survivor's insurance benefits or copy of check showing the amount of the award.) 13. IF YOU ARE NEITHER THE SPOUSE OF THE DECEASED OR CHILD OF THE DECEASED UNDER 18 YEARS OF AGE OR UNDER 23 YEARS ENROLLED AND ATTENDING AS A FULL TIME STUDENT IN ANY ACCREDITED EDUCATIONAL INSTITUTION, ENTER THE FOLLOWING INFORMATION: a. Were you wholly or partially dependent on the deceased for your support? _________________ b. If partially dependent, to what degree? _____________________ c. I own property as follows: (1) Real estate, assessed value $____________________________, from which I receive an income of $_______________ annually and on which there is an indebtedness of $ ____________________. . (2) What other sources of income do you have? (Name each source and give amounts derived from each source named.) AMOUNT SOURCE 14. IF YOU ARE A CHILD OR DEPENDENT GRANDCHILD, DEPENDENT BROTHER OR DEPENDENT SISTER, AT LEAST 18 YEARS OF AGE BUT UNDER 23 AND ENROLLED AND ATTENDING AS A FULL TIME STUDENT IN ANY ACCREDITED EDUCATIONAL INSTITUTION, ENTER THE FOLLOWING INFORMATION AND ATTACH CERTIFICATION OF ATTENDANCE, IF AVAILABLE FROM SUCH INSTITUTION. Name of Student Name & Address of Educational Institution Date Attendance Began 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