002 002 DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION AGREEMENT FOR COMPENSATION002 FOR DEATH002 DECEASED222S SOCIAL SECURITY NUMBER OR WC ID NUMBER - - DECEASED EMPLOYEE First name Last name Date of birth Date of death --MM DD YYYY --MM DD YYYY DEPENDENT/GUARDIAN/PERSONAL REPRESENTATIVE First name Last name Address Address City/Town State ZIP County Telephone INJURY INFORMATION Part of body injured Nature of injury Accident/injury description narrative Check if occupational disease DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone FEIN INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN Contact NAIC code or Insurer code Insurer/TPA claim # NOTICE: Agreement should be clearly completed, (preferably typed) and uploaded in accordance with the provisions of EDI Implementation Guide. A copy must be sent to the dependent/guardian/personal representative. Wage information must be completed in accordance with Section 309 of the Pennsylvania Workers222 Compensation Act, and sent to the Dependent/ Guardian/Personal Representative. We, the following persons, dependents of the aforementioned deceased employee, and the undersigned employer, agree upon the following matters which determine dependents222 rights to compensation and its amount and duration. Employer Representative222s signature DATE OF BIRTH NAME RESIDENCE MM-DD-YYYY RELATIONSHIP American LegalNet, Inc. www.FormsWorkFlow.com 002 002 002 - ---Compensation was paid beginning and ending for the employee222s MM DD YYYY MM DD YYYY disability prior to death. The compensation payable under the agreed facts, based on the average weekly wage of $ , is as follows: FROM THROUGH WEEKLY RATE MM-DD-YYYY MM-DD-YYYY #WEEKS/#DAYS REASON FOR CHANGE AMOUNT $ $ $ $ $ $ $ $ $ $ $ $ $ $ Amount expended for medical $ Amount expended for burial $ Further matters agreed upon: Date of agreement -- MM DD YYYY Dependent/Guardian/Personal Representative222s signature Claims Representative222s name (typed/printed) Claims Representative222s signature Telephone . Employer Information Services Claims Information Services Hearing Impaired Email *338*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com