C12 NON - DEPENDENT(S) REPORT OF DEATH CLAIMS DIVISION SFN 10013 (01 /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. w orkforce s afety.com Please print or type using black or blue ink and return to WSI. This form should be completed by surviving non-dependent relatives of a deceased employee when there is no surviving spouse or dependent child(ren). Application for death benefits in all cases of injury resulting in death must be made by the beneficiary or administrator of the decedent within two years. The following section of law details the benefits: Section 65 - 05 - - Dependency Payments In Certain Cases. If the death of an employee with no surviving spouse or children results from an i njury within the time specified in Section 65 - 06 - 16, WSI shall pay a lump sum, equal to five percent of the maximum total death benefits in accordance with the current law, to the survivin g non - dependent child, or in equal shares to the surviving non - depen dent children. In the event that no non - dependent child is living, the sum provided herein shall be paid in equal shares to the surviving parents of the deceased, and if there are none, then to the de ceased ere are no living brothers or sisters, the sum herein shall be paid in equal shares to the SECTION 1 - Claim number (First name) (Last name) Social Security number* Date of birth Sex Female Male Marital status of deceased worker Single Married Mailing address (Street address, PO Box number) City State ZIP code SECTION 2 Non - Non - (First name) (Last name) Social Security n umber* Date of birth Mailing address (Street address, PO Box number) City State ZIP code Telephone number Relationship to deceased Non - (First name) (Last name) Social Security number* Date of birth M ailing address (Street address, PO Box number) City State ZIP Code Telephone number Relationship to deceased Please submit a photocopy of the following documents - if available Death Certificate Autopsy Report if performed SECTION 3 - Accident information Date of accident Time of accident AM PM Date of death SECTION 4 Mailing address (Street address, PO Box number) City State ZIP code Form continued on next page. Please submit all pages to WSI. American LegalNet, Inc. www.FormsWorkFlow.com NON DEPENDENT(S) REPORT OF PAGE 2 OF 2 SFN 10013 (01/2015) Claim number (First name) (Last name) C12 SECTION 5 Release of information/fraud warning/signature Release of information I understand and agree that North Dakota law determines all my rights and obligations to and from WSI. I authorize any medica l r mi litary agency, any government benefit agency including the Social Security Administration, and any educational agency or institution to release to WSI, its agents and attorneys, any and all information or records, including all prior records as well as tho se pertaining to mental health, alcohol, or drug abuse, and HIV/AIDS/AIDS - related illness. I authorize healthcare providers to respond to WSI regarding my injury, including request for conclusions and opinions not otherwise contained within existing medica l records. In addition, 21 Sec. 1232g. This authorization continues while I have any claim open or pending before WSI. WSI is exempt from HIPAA regulations. I authorize WSI to release any information or records about my claim to third parties or their insurers for the purpose of re solving claims against third parties. I authorize the release of any medical information related to my claim to my employer. 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 income or an increase in income from employment, in connectio n with any claim or application for workers compensation benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fine s, or both. These criminal penalties are applicable to all persons dealin g with WSI, including injured workers, employers, medical providers, and attorneys. Signature B y signing this form, I acknowledge that I have read and understand the release of information and fraud w arning. I understand that falsifying this claim or mak ing a false statement regarding this claim may be a felony, punishable by substantial fines and imprisonment. I authorize the release of information and agree that statements in this form are true and accurate. Each beneficiary applying for benefits must sign this application Date signed Date signed SECTION 6 Additional information or comments * 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. To report an instance of fraud, contact the ND Fraud and Safety Hotline at 800-243-3331. American LegalNet, Inc. www.FormsWorkFlow.com