Notice to Beneficiary of Entitlement to Benefits IMPORTANT Please carefully read this letter, as it contains important information about your benefits. As the beneficiary of an eligible claim, you may request to receive your benefit payments directly at the age of 18. Your benefits will continue until your 19th birthday. Starting when you turn 19 and ending with your 26th birthday, you may be eligible to receive up to an additional 48 months of benefits while you are completing secondary education, obtaining your general education certificate (GED), or attending community college, college or university, or vocational or technical training.1 You may claim your benefits at any time by providing documentation that you are in school. Documentation may include an enrollment letter, transcripts, or a progress report from your school. You may request benefits by completing this form and returning it to: [INSURER/SELF-INSURED EMPLOYER/ SERVICE COMPANY NAME] [ADDRESS] [CITY, STATE, ZIP CODE] After receiving this form and documentation, we will determine your eligibility for benefits and notify you with our decision and further instructions. If you have questions about this form or benefits, contact us at [PHONE NUMBER]. If you need more help filling out this form, please contact the Ombudsman for Injured Workers at 800-927-1271 (toll-free) or the Oregon Workers222 Compensation Division at 800-452-0288 (toll-free). I want to (check one or both): R eceive my benefit payments directly (complete Section A only) Claim higher education benefits (complete both Sections A and B) Section A : Personal i nformation Deceased w orker222s name: Claim number: Your name: Your address: City, state, ZIP code: Your phone number: Your email address: Section B : School or i n stitution i nformation Name of school or institution: Address: City, state, ZIP code: Phone number: Current e nrollment dates (attach documentation) : From: To: ( month/day/year ) (month/day/year) By my signature, I certify that all of the information I have provided on this form is true and accurate . Printed name Signature Date 440 - 5332 (1/18/DCBS/WCD/WEB) 1 To be eligible for benefits while attending college, university, or vocational or technical training, you must be enrolled at least half-time. American LegalNet, Inc. www.FormsWorkFlow.com