DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION FATAL CLAIM PETITION FOR002 COMPENSATION BY DEPENDENTS002 OF DECEASED EMPLOYEES002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth Date of death If deceased - Dependent/Guardian/Personal Representative First name Last name Address Address City/Town State ZIP County Telephone U.S. Citizen Yes No INJURY INFORMATION Description of injury or illness Check if occupational disease DATE OF INJURYWCAIS 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 # 1.Business of employer2.Time of injury (hour) a.m. p.m. 3.The cause of death wasas given by 4.The deceased employee incurred the following medical bills (give name of health care provider, address, type oftreatment and bill in space below) related to the fatality.GIVE NAME AND ADDRESSES. IF NONE, SO STATE. 5.Expenses for the burial amounted to $. . Amount paid by employer $ .. 6.The wages of deceased employee at the time of accident were $. . hour day week 7.Notice of injury and/or death was given to employer on by NAME OF PERSON REPORTING INJURY/DEATH MM DD YYYY002 in the following manner -- STATE WHEN AND TO WHOM NOTICE WAS GIVEN AND IN WHAT MANNER 8.Compensation for disability was paid to the deceased fromMM DD YYYY MM DD YYYY Total amount paid was $. . to -- -- American LegalNet, Inc. www.FormsWorkFlow.com NAME ADDRESS DATE OF BIRTH MM-DD-YYYY RELATIONSHIP US CITIZEN Yes No Yes No Yes No Yes No Yes No 11.Petitionerwas was not living with the deceased employee at the time of his or her death. 12.The petitioner is is not a widow/widower of the deceased employee. a.If petitioner is a widow or widower, state where ceremony was performed and give date of marriage.b.Was marriage a common law marriage? Yes No 14.Other15.Is there other pending litigation in this case Yes No If yes, explain below. PLEASE ENTER MY APPEARANCE FOR PETITIONER: PA Attorney ID number Firm name Date of petitionAddress -- Address MM DD YYYY City/Town State ZIP Telephone (typed/printed) NEmployer Information Claims Information Services Email Services Hearing Impaired *363*Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com