COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS’ COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 FATAL CLAIM PETITION FOR COMPENSATION BY DEPENDENTS FOR DEATH COVERED BY THE PENNSYLVANIA OCCUPATIONAL DISEASE ACT Deceased Employee Deceased’s Social Security Number: Date of Injury: - / MM - / DD YYYY PA BWC Claim Number: (IF KNOWN) Employer First Name Last Name Name _______________________________ _________________________________________ ___________________________________________________________________________ Street 1 Date of Birth ______/______/________ MM DD YYYY Date of Death ______/______/________ MM DD YYYY ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code Dependent __________________________________________ County First Name Last Name _______________________________ Street 1 _________________________________________ VS. __________-_______ FEIN (______) _______-_______________ ___________________________________________________________________________ City/Town State Zip Code __________ Telephone __________-_______ _________________________________ Telephone ___________________________________________________________________________ Street 2 __________________________________________ County __________ _________________________ Insurer or Third Party Administrator (if self-insured) Name ___________________________________________________________________________ Street 1 ___________________________________________ (______) _______-_______________ ___________________________________________________________________________ Street 2 Injury Description of Injury and Cause of Death ___________________________________________________________________________ ___________________________________________________________________________ City/Town State Zip Code ___________________________________________________________________________ __________________________________________ Telephone __________ Bureau Code (______) _______-_______________ County ____________________________ ___________________________________________________________________________ ___________________________________________________________________________ ______________________________ Claim Number FEIN ______________________________ ___________________________ __________-_______ ___________________________________________________________________________ ___________________________________________________________________________ 1. Death was a result of □ Silicosis □ Anthraco-Silicosis □ Asbestosis 2. The deceased employee has been employed in a hazardous occupation in the Commonwealth of Pennsylvania having a G Silica hazard G Asbestos hazard for at least two years in the aggregate during the ten years preceding disability as follows: NAME OF EMPLOYER IN PENNSYLVANIA ADDRESS DATES OF EMPLOYMENT FROM TO (MM/DD/YYYY) (MM/DD/YYYY) _________________________________________________ _____________________________________________________ ________/________/__________ ________/________/____________ _________________________________________________ _____________________________________________________ ________/________/__________ ________/________/____________ _________________________________________________ _____________________________________________________ ________/________/__________ ________/________/____________ _________________________________________________ _____________________________________________________ ________/________/__________ ________/________/____________ _________________________________________________ _____________________________________________________ ________/________/__________ ________/________/____________ 3. The deceased employee was last engaged in a hazardous occupation having a G Silica hazard G Asbestos hazard in the employ of the defendant on _____/_____/_________. MM DD YYYY 4. The deceased employee became totally disabled on _____/_____/_________. MM LIBC-384 REV 4-04 (Page 1) DD YYYY (OVER) American LegalNet, Inc. www.USCourtForms.com 5. The deceased employee received aid from the following doctors and/or hospitals: (Give names and addresses. If none, so state.) __________________________________________________________________________________________________ __________________________________________________________________________________________________ 6. Expenses of the last illness and burial amounted to $__________._____ Amount paid by the employer $__________._____ 7. The average weekly wage of the deceased employee in the employ of the defendant employer was $________._____. 8. Was compensation paid to the deceased employee between the time total disability began and the date of his/her death? G Yes G No If Yes, payments began on ____/____/______ MM DD YYYY 9. Dependents of the deceased employee are as follows: NAME RESIDENT DATE OF BIRTH RELATIONSHIP (MM/DD/YYYY) _________________________________________________ _____________________________________________________ ________/________/__________ _____________________________ _________________________________________________ _____________________________________________________ ________/________/__________ _____________________________ _________________________________________________ _____________________________________________________ ________/________/__________ _____________________________ _________________________________________________ _____________________________________________________ ________/________/__________ _____________________________ _________________________________________________ _____________________________________________________ ________/________/__________ _____________________________ 10. The petitioner G is G is not a. a widow/widower of the deceased. If petitioner is a widow or widower, state where ceremony was performed and give date of marriage. _______________________________________________________________________ _____/_____/______ MM b. Was marriage a common law marriage? DD YYYY G Yes G No 11. The claimant has provided the following additional information: ________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ WHEREFORE, the aforementioned claimant asks that the Bureau make an award that the defendant shall pay such compensation as due under the Pennsylvania Occupational Disease Act. DATE OF THIS NOTICE: ____/____/_______ MM DD YYYY PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney I hereby certify that a copy of this Petition has been served on the opposing party. Name __________________________________________________ ___________________________________________________________________________ Street 1 SIGNATURE OF PETITIONER OR REPRESENTATIVE Petitioner ___________________________________________________________________________ Firm Name ___________________________________________________________________________ Street 2 First Name Last Name _______________________________ Signature ______________________________________________ ___________________________________________________________________________ City/Town State Zip Code __________________________________________ __________ __________-_______ Telephone PA Attorney ID Number ________________________________________________________________________________ (______) _______-________________________ ________________________________ NOTICE: This petition should be clearly completed (preferably typed) and original mailed to the Bureau at the address in the upper left corner on the front. Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. LIBC-384 REV 4-04 (Page 2) Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.USCourtForms.com