Additional Information for Death Benefits Instructions • Please print or type. Do not use red ink. Name of deceased Eligibility for death benefits is generally given to the deceased's biological dependents, current spouse, those persons receiving sole support and others who rendered services pertaining to this death. Date of death Claim number • Divorce decrees and/or death certificate from any previous marriage(s) of deceased • Divorce decrees and/or death certificate from any previous marriage(s) of current spouse Supporting documents required • Death certificate of the deceased • Birth certificate(s) of spouse and dependents • Marriage certificate from current spouse 1. This application is made on behalf of the persons named below who were dependent on the deceased for support. Social Security number Name Relationship to deceased Person completing this form (applicant, please print ) Wholly Dependency Partially Date of birth 2. For persons in #1 (other than current spouse and/or dependent minor children) who were dependent on the deceased for support, complete the information requested below. Weekly Amount Contributed by Deceased Name Date of Last contribution Other weekly income 3. The person(s) named below are applying for reimbursement of payment made on behalf of the deceased. (Please attach any service invoice, bill or proof of payment.) 4. Was deceased residing with you at time of death? Street address Yes 5. Was deceased previously married? Date of payment Amount of payment Name Yes No No Provider/risk number If no, give deceased's address and include county. City State Nine-digit ZIP code County If yes, list full names of spouse(s) and how the marriage(s) terminated. 6. Did deceased have any children from the former marriage(s)? 7. Was the deceased 's current spouse previously married? terminated. Yes Yes No No If yes, list names, addresses and ages of such children. If yes, list full name of former spouse(s) and how the marriage(s) 8. Did deceased's current spouse have any children from the former marriage(s)? children. Yes No If yes, list name(s), address(s) and age(s) of such I certify the information on this form is true and correct. I understand that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain benefits/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. (Signature of Applicant) ( ) (Address) (Telephone number ) (City, State, nine-digit ZIP code, County) BWC-1108 (Rev. 09/22/2010) C-5 (C-5-A Combined within) American LegalNet, Inc. www.FormsWorkFlow.com