State of New York - Workers' Compensation Board CLAIM FOR VOLUNTEER AMBULANCE WORKERS' BENEFITS 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. Does this claim involve disease or b. Death certificate. malfunction of the heart or of one or more c. Proof of relationship such as birth certificate, marriage certificate, adoption papers, etc. coronary arteries? d. Itemized funeral bill. No Yes 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 VOLUNTEER AMB. WORKER AMBULANCE COMPANY POLITICAL SUBDIVISION LIABLE CARRIER ADDRESS (Give No, Street,City, State and Zip Code) Apt. No. Apt. No. CLAIMANT I hereby make claim for death benefits payable under the Volunteer Ambulance Workers' Benefit Law for injury to the deceased volunteer ambulance worker named above sustained in the line of duty and in support of this claim, I submit the following information: 1. a. Death occurred on (Date)______________________at (Place)_________________________________________________________________________ b. Date of injury _________________________at_________o'clock__________M. ( Attach Death Certificate If Available) c. Address and community where injury occurred ____________________________________________________________________________________ d. Was volunteer ambulance worker injured in the line of duty in the jurisdiction of his/her ambluance district or political subdivision? Yes No If volunteer ambulance worker was injured in the line of duty involving an assistance call from another locality, give name of other ambulance district or political subdivision __________________________________________________________________________________________________________ e. Cause of injury (Describe fully what factors or events led up to or contributed to the injury.)________________________________________________ __________________________________________________________________________________________________________________________ f. Nature of injury and part of body injured___________________________________________________________________________________________ Note: Attach a medical report, if available. 2. ATTENDING PHYSICIAN 3. LAST PHYSICIAN OR HOSPITAL 4. UNDERTAKER 5. PERSON WHO PAID UNDERTAKER BILLS Name Address 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 25 years of age and enrolled and attending as full-time students in any accredited educational institution? Yes No (SEE INSTRUCTIONS ON REVERSE SIDE) 10. Survivors or dependents of the deceased - attach additional sheet if necessary Name Address Birth Date Relationship NOTE: Attach proof of relationship such as birth certificate, marriage certificate, adoption papers, etc., if available. 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. VAW-62 (1-11) THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION 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 (date) ________________________________________at (place)__________________________________ by (person performing ceremony) _________________________________________________Attachmarriage certificate if available. 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 25, 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 NEITHER THE SPOUSE OF THE DECEASED OR CHILD OF THE DECEASED UNDER 18 YEARS OF AGE OR UNDER 25 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.) SOURCE AMOUNT 13. IF YOU ARE A CHILD OR DEPENDENT GRANDCHILD, DEPENDENT BROTHER OR DEPENDENT SISTER, AT LEAST 18 YEARS OF AGE BUT UNDER 25 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 SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT. I certify that copy of this claim was filed with______________________________________________________________________________________________ _________________________________________ ________________________________________________________on_______________________________ (Title of Officer) (Political Subdivision Liable for Benefits) (Claimant's Signature) (A person on behalf of claimant) (Relationship) Telephone No. Telephone No. (Name of Officer) Dated___________________________Signed by____________________________________________