Claim For Benefits Under Law Enforcement Officers Firemens Rescue Squad Workers And Civil Air Patrol Members Death Benefits Act
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Claim For Benefits Under Law Enforcement Officers Firemens Rescue Squad Workers And Civil Air Patrol Members Death Benefits Act Form. This is a North Carolina form and can be use in Workers Comp.
Loading PDF...
Tags: Claim For Benefits Under Law Enforcement Officers Firemens Rescue Squad Workers And Civil Air Patrol Members Death Benefits Act, North Carolina Workers Comp,
NORTH CAROLINA INDUSTRIAL COMMISSION
DOCKET NO.___________________________
CLAIM FOR BENEFITS UNDER THE LAW ENFORCEMENT OFFICERS’, FIREMEN’S, RESCUE SQUAD
WORKERS’ AND CIVIL AIR PATROL MEMBERS’ DEATH BENEFITS ACT, G. S. 143-166, ET SEQ.
___________________________________
(Print Name of Claimant)
______________________, being first duly sworn, deposes and says:
(County)
1.
This claim is filed for benefits under the Law Enforcement Officers’ Death Benefits Act by
reason of the death of ________________________________________________________________________
2.
The said employee was killed in the discharge of his/her official duties as a full-time law
enforcement officer on the ________ day of _______________________________________, 200_____.
3.
The injury and death occurred in the following manner: ________________________________________
_____________________________________________________________________________________________
4.
The name of the employer was ________________________________________________________________
(address)____________________________________________________________________________________
5.
Workers’ compensation benefits have been paid or are being paid by reason of this death
and I. C. File Number _________________________ has been assigned to said workers’ compensation
claim.
6.
The name, address, and social security number of the surviving spouse are:
(Name)__________________________________________________________ (SSN)_______________________
(Address)____________________________________________________________________________________
The names, dates of birth, addresses, and social security numbers of the minor children of this
employee are (please list additional children on back of this form):
(Name)___________________________________ (Relationship)_____________ (SSN)___________________
(Address)____________________________________________________________________________________
(Name)___________________________________ (Relationship)_____________ (SSN)___________________
(Address)____________________________________________________________________________________
7.
The surviving spouse was , was not residing with employee on the date of the injury or death.
Date of marriage:__________________________ Place of marriage:_________________________________
8.
There are no children or eligible surviving spouse. The eligible beneficiaries are listed below:
(Name)__________________________________________________________ (SSN)_______________________
(Address)____________________________________________________________________________________
(Name)__________________________________________________________ (SSN)_______________________
(Address)____________________________________________________________________________________
9.
The surviving spouse resided with employee continuously for 6 months prior to death? Yes__ No__
______________________________________________
(Signature of Claimant)
Subscribed and sworn to before me this
the _____ day of _________________, 200____.
________________________________________
(Address)
______________________________________________________
Signature and Seal of Notary Public or Clerk of Court
My Commission expires:______________________________
PLEASE SUBMIT TO:
MS. LINDA LANGDON, DOCKET DIRECTOR
4336 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-4336
American LegalNet, Inc.
www.USCourtForms.com
