OF DEATH CLAIMS DIVISION SFN 10011 (0 9 /201 5 ) 1600 E C entury A ve , S te 1 PO Box 5585 Bismarck ND 58506 - 5585 Telephone 800 - 777 - 5033 Toll Free Fax 888 - 786 - 8695 TTY ( hearing impaired ) 800 - 366 - 6888 Fraud and Safety Hotline 800 - 243 - 3331 www. workforces afety.com Please print or type using black or blue ink and return to WSI. SECTION 1 Deceased worker information Claim n umber (F irst name) (L ast name) Social Security n umber * Date of birth Sex Female Male Marital status of deceased worker Single Married M ailing address ( S treet address, PO Box number) City State ZIP c ode SECTION 2 Surviving spouse/dependent(s) Spouse or dependent(s) (F irst name) ( L ast name) Relationship to deceased Date of birth Social S ecurity number* T elephone number M ailing address ( S treet address, PO Box number) City State ZIP c ode SECTION 3 Accident i nformation Date of accident Time work started that day AM PM Time of accident AM PM D ate of death Where did accident happen? (City) (County) (State) What was deceased worker hired to do? (J ob title or duties) How did accident happen? If death was due to heart attack or stroke, was deceased worker under any unusual stress or strain? Yes No If yes, please explain . T reatin g doctor(s) name Address of treating doctor (S treet address, PO Box number) City State ZIP c ode Name of witness(es) to the accident Telephone number of witness(es) to the accident SECTION 4 Employer information Rate class M ailing address (S treet address, PO Box number) City State ZIP code Telephone number Do you question this claim? Yes No If yes, please explain on the back of this form . SECTION 5 Fraud warning/signature Fraud warning Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of ts will forfeit any future benefits and may be guilty of a felony wh ich is punishable by imprisonment, substantial fines, or both. These criminal penalties are applicable to all persons dealing with WSI, including injured workers, employers, medical providers, and attorneys. Signature By signing this form, I acknowledge that I have read and understand the f raud w arning. I understand that falsifying this claim or making a false statement regarding this claim may be a felony, punishable by substantial fines and imprisonment. I authorize a nd agree that statements in this form are true and accurate. Employer signature Title Date signed C9 * In compliance with the Federal Privacy Act of 1974, disclosure of the Social Security number on this form is mandatory pursuant to N.D.C.C. 247 65-05-02. The Social Security number is used for identification and verification purposes. Failure to provide this information may result in a delay in processing your request. American LegalNet, Inc. www.FormsWorkFlow.com