Annual Death Benefits Questionnaire · BWCrecordsindicateyouarereceivingdeathbenefitsfortheclaimnumberlisted. · Pleasesupplyrequestedinformationandreturnintheenvelopeprovided. · Ifyouhavequestions,pleasecontacttheclaimsservicespecialist(CSS)listedbelow. Nameofdeceasedworker Nameof Address City dependent, survivingspouse, guardian, other Dateofbirth Date Claimnumber SocialSecuritynumber Telephonenumber ZIPcode () State 1. Isthisyourcurrentnameandaddress? Yes No 2. Ifno,pleaseprovidethecorrectnameand/oraddress. Name Address City State ZIPcode TobecompletedbysurvivingspouseONLY: 3. Haveyouremarried? Yes No 4. Ifyes,completefollowinginformation.Ifno,gotoquestion5. Dateofmarriage County State 5. Tobecompletedbysurvivingspouseorguardian.Pleaseverify/completethefollowinginformationforanydependents receivingdeathbenefits.Ifyouneedadditionalspace,pleaseusethebackofthisform. Name of dependents Age Date of birth Social Security number Status of dependent full-time student/disability IcertifyIhaveanswered/verifiedtheabovequestionstruthfullyandcompletely. Signatureof dependent, survivingspouse, guardian, other Date CSSname Serviceofficeaddress City,State,ZIPcode Telephone Fax Iunderstandthatanypersonwhoknowinglymakesafalsestatement,misrepresentation,concealmentoffactoranyother actoffraudtoobtainbenefits/compensationasprovidedbyBWCorself-insuringemployers,orwhoknowinglyaccepts compensationtowhichthatpersonisnotentitled,issubjecttocriminalprosecutionandmay,underappropriatecriminal provisions,bepunishedbyafineorimprisonmentorboth. BWC-1158 (Rev. 9/22/2010) C-39 American LegalNet, Inc. www.FormsWorkFlow.com