Additional Information For Death Benefits
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Additional Information For Death Benefits Form. This is a Ohio form and can be use in Injured Workers Workers Comp.
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Tags: Additional Information For Death Benefits, BWC-1108, Ohio Workers Comp, Injured Workers
Additional Information
for Death Beneļ¬ts
Instructions
Do not use red ink.
Supporting documents required
Name
Social Security
number
Relationship
to deceased
Wholly
Dependency
Partially
Date of birth
Name
Date of Last
contribution
Other weekly
income
Name
C-5
Weekly Amount
Contributed
by Deceased
Amount
of payment
Date
of payment
Provider/risk
number
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