Claim number BWC - 1198 (Rev. Feb. 12 , 2018 ) C - 6 Instructions Submit this form with supporting documentation via fax to 1 - 866 - 336 - 8352, or send it to your local BWC claims office. Name of decedent Date of death Spouse or dependent Required documentation A copy of a death certificate, obituary or some other proof of death of the decedent Spouse of the decedent a copy of your marriage certificate Dependent child of the decedent (A dependent child is a minor, a student between the ages of 18 and 25 years, or a physically or mentally incapacitated adult.) a copy of your birth certificate, and: o If you are a student between the ages of 18 and 25 years, proof of enrollment in an accredited educational institution ; o If you are more than 18 - years - old with a physical or mental disability that prevents you from working, medical documentation describing your physical or mental disability. On behalf of th e estate documentation from the probate court verifying your capacity to act on behalf of the estate Name Spouse Social Security number Date of birth Dependent Address Phone number City State ZIP code Email address If you are the spouse, was the decedent residing with you at time of death? Yes No If no, please explain why you were living separately. Complete this section if you are Fiduciary name Tax identification number Address Phone number City State ZIP code Email address Complete this section if you are not a spouse or dependent child and are only requesting reimbursement or payment for services Required documentation from individual or provider seeking payment of, or reimbursement of payment for services (e.g., funeral expenses) A copy of the service invoice, or if seeking reimbursement, a copy of the paid bill or other proof of payment. Redact account numbers from any supporting documentation submitted as proof of payment. If you are a provider seeking payment, you must also prov ider your tax ID number. Payment or reimbursement is limited to the amount of accrued compensation available, if any. Name (Individual or business) Social Security number or taxpayer ID Date of birth (If an individual) Address Phone number City State ZIP code Email address S ignature I certify the information on this form is true and correct to the best of my knowledge. I understand any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain benefits and/or compensation as provided by BWC or self - insuring employers, or who knowingly accepts compensation to which that person is not entitled, is subject to criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. Name of person applying for accrued compensation (please print) Date Signature of person applying for accrued compensation American LegalNet, Inc. www.FormsWorkFlow.com