Application for Death Benefits and/or Funeral Expenses BWC - 1108 (Rev. May 30 , 2019) C - 5 Please reference page two of this form for information regarding evidence that you must submit with the application. You can submit this form and supporting documentation via fax to 1 - 866 - 336 - 8352, or send it to your local BWC customer service office. N ame of decedent Social Security number Claim number if known Date of death 1 Check all that apply: I am applying for death benefits and, if applicable, funeral expenses (check one of the boxes below) and proceed to section 3 . o For myself o For myself and other dependents of the decedent o On behalf of dependents of the decedent I am only . Proceed to section 2. 2 This section is completed when only requestin g reimbursement of funeral expenses or other services Complete this section and proceed to section 6 Name Street address, city , state , ZIP code Relationship to decedent if applicable Social Security number or Federal tax ID # Cell/phone number with area code Email address 3 List all persons who were dependent on the decedent for support (attach sheet for additional dependents if needed) First dependent Name Street address, city , state , ZIP code Relationship to decedent Social Security number Cell / phone number with area code and email address Date of birth Second dependent Name Street address, city , state , ZIP code Relationship to decedent Social Security number Cell / phone number with area code and email address Date of birth Third dependent Name Street address, city , state , ZIP code Relationship to decedent Social Security number Cell / phone number with area code and email address Date of birth 4 Complete this section if you are the Was the decedent residing with you at time of death? Yes No If no, please explain why you were living separately. Were you previously married? Yes No 5 Deced ent information Was d ecedent married more than once? Yes No Does the decedent have any children not listed in section 3? Yes No 6 Signature I am applying for death benefit s - related injuries. I affirm that laws for my claim, and I waive and release my right to file for and receive compensation and benefits under the laws of any o ther state for this claim. I request payment for compensation and/or benefits as allowable. I certify the information on this form is true and correct to the best of my knowledge. I understand that 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 provide d by BWC or self - insurin g employers, or who knowingly accepts compensation to which that person is not entitled, is subject to criminal prosecution a nd may, under appropriate criminal provisions, be punished by a fine or imprisonment or both. Person completing this form (please print) Date Signature of person completing this form Cell/phone number American LegalNet, Inc. www.FormsWorkFlow.com Application for Death Benefits and/or Funeral Expenses BWC - 1108 (Rev. May 30 , 2019) C - 5 (BWC), we feel your loss and want to ensure you or your family receive all eligible benefits. These instructions are meant to help ease the application process, but please know we are here to answer any questions you may have. If your family member died because of a work-related injury or occupational disease, as his or her surviving dependents you may qualify for compensation, including funeral expenses. When BWC allows a death benefits claim, reasonable funeral expenses may be paid or reimbursed up to a maximum amount allowable per Ohio law. Family members who may be eligible for benefits due to a work-related death include: Spouse.Dependent children under 18 years old.Dependent children 18 to 25 years old who are attending an accredited educational institution.A mentally or physically incapacitated child 18 or older who is unable to support his or herself.Other family members with proof of dependency upon the decedent. Instructions for completing the Application for Death Benefits and/or Funeral Expenses (C - 5) These instructions detail the information and supporting documentation you need to c omplete the application. Please fully complete each section of the C - 5 form before submitting it to BWC. Section 1 Check the box indicating the benefits being requested. Section 2 Complete only when requesting reimbursement of funeral expenses or other services. oIf the claimant for funeral expenses is not the employer of record, the claimant must include: Social security number.Date of birth.Email address of the claimant requesting payment (if available).oThis information is required for BWC to enter the request into the claims management system to issuepayment. Section 3 List all persons who were dependent on the decedent for support Attach sheet for additional dependents, if needed If a guardian of a dependent, please include your information. This information is required for BWC to enter the request into the claims management system to issue payment Section 4 Section 5 Check the box es that apply. Section 6 Please provide the name (printed), signature, date and phone number of the person completing the C - 5. Supporting documentation for death benefits The list below details when and the types of documentation a dependent will need to provide to BWC to support his or her request for death benefits and, if applicable, funeral expenses. Submitting the needed documentation with the C - 5 as soon as possible w ill help us make a quicker decision. A BWC claims service specialist will advise the claimant if any additional documentation or information is needed . Provide the following documents, when applicable: First Report of Injury (FROI - 1) completed by dependen t or guardian of minor children that identifies the Employer (New claim only) Medical causal relationship statement by a physician Final Death Certificate (must list the cause of death) Medical evidence to establish a causal relationship between the deat h and industrial injury . Wages Traffic/accident report Police report American LegalNet, Inc. www.FormsWorkFlow.com Application for Death Benefits and/or Funeral Expenses BWC - 1108 (Rev. May 30 , 2019) C - 5 EMS/Ambulance report Coroner r eport Autopsy r eport Toxicology r eport Funeral Expenses/ Service Reimbursement Copy of the service invoice or paid funeral bill Surviving Spouse Marriage certificate Social s ecurity c ard , if available Proof of residence with the decedent at the time of death (e.g., a voided personal check with both names and the same address) If the surviving spouse ha d been previously married, a divorce decree or death cer tificate of ex - spouse . If the surviving spouse was not residing documentation supporting that reason (e.g., court records, police reports) . If the spouse and decedent were not residing together at the time of death, documentation that establishes dependency. Child /Children of the decedent Birth certificate for minor children that shows the decedent is the parent of the child. If that is not available, a court order establishin g paternity or an adoption decree. Guardianship documentation that shows a person has guardianship over the estate and/or children . Guardianship and/ or custody documents if the child is not living with the parents Adoption papers Social Security c ard (s), if available Family support order, if applicable Paternity test results , if applicable , or legal acknowledgement of paternity; Resource Local Child Support Enforcement Agency If the child is more than 18 years old and mentally or physically unable to work, medical records verifying the . If the child is between the ages of 18 and 25 and enrolled in college fulltime (Generally, 12 hours or greater): Class registration and/or class schedule Report of grades for completed courses Proof of payment of fees and/or tuition School transcript Letter of acceptance into an accredited educational institution Non - t raditional education will be evaluated on a case - by - case basis If the child is a stepchild of the decedent: The marriage certificate showing the decedent was married to the other par