State of New York - Workers' Compensation Board CLAIM FOR VOLUNTEER FIREFIGHTERS' 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. Yes No 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 ADDRESS (Give No, Street,City, State and Zip Code) Apt. No. VOLUNTEER FIREFIGHTER FIRE COMPANY POLITICAL SUBDIVISION LIABLE FOR BENEFITS CARRIER Apt. No. CLAIMANT I hereby make claim for death benefits payable under the Volunteer Firefighters' Benefit Law for injury to the deceased volunteer firefighter 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 firefighter injured in the line of duty in the jurisdiction of his/her fire district or political subdivision? Yes No If volunteer firefighter was injured in the line of duty involving an assistance call from another locality, give name of other fire 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. American LegalNet, Inc. www.FormsWorkFlow.com VF-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________________________________________________________________________________________ (Name of Officer) ________________________________________ _________________________________________________on_______________________________ (Title of Officer) (Political Subdivision Liable for Benefits) (Claimant's Signature) Telephone No. Dated___________________________Signed by__________________________________________________ ______________________________or Signed by________________________