Deceased’s Social Security Number: FATAL CLAIM PETITION FOR COMPENSATION BY DEPENDENTS FOR DEATH RESULTING FROM OCCUPATIONAL DISEASE 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 TTY 800-362-4228 Date of Injury: - / / MM DD YYYY PA BWC Claim Number: (IF KNOWN) (Not to be used where death results from silicosis, anthraco-silicosis and asbestosis. Deceased Employee - Employer First Name Last Name Name _______________________________ _________________________________________ ___________________________________________________________________________ Street 1 Date of Birth ______/______/__________ MM DD YYYY ___________________________________________________________________________ Street 2 Date of Death ______/______/__________ MM DD YYYY ___________________________________________________________________________ City/Town State Zip Code Dependent __________________________________________ County First Name Last Name _______________________________ Street 1 _________________________________________ ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County __________ Telephone __________ __________-_______ _________________________________ Telephone VS. FEIN (______) _______-__________________ ______________________________ Insurer or Third Party Administrator (if self-insured) __________-_______ Name ___________________________________________ (______) _______-_______________ ___________________________________________________________________________ Street 1 Injury ___________________________________________________________________________ Street 2 Description of Injury and Cause of Death ___________________________________________________________________________ ___________________________________________________________________________ City/Town State Zip Code ___________________________________________________________________________ __________________________________________ Telephone __________ Bureau Code ___________________________________________________________________________ (______) _______-__________________ County ______________________________ ___________________________________________________________________________ _________________________________ Claim Number FEIN ___________________________________________________________________________ _________________________________ ______________________________ __________-_______ The petitioner respectfully alleges that: 1. Dependents of the deceased employee are as follows: NAME RESIDENCE DATE OF BIRTH RELATIONSHIP (MM/DD/YYYY) _ _________________________________________________ _____________________________________________________ ________/________/__________ ________/________/____________ _________________________________________________ _____________________________________________________ ________/________/__________ ________/________/____________ _________________________________________________ _____________________________________________________ ________/________/__________ ________/________/____________ _________________________________________________ _____________________________________________________ ________/________/__________ ________/________/____________ _________________________________________________ _____________________________________________________ ________/________/__________ ________/________/____________ 2. The petitioner is is not a widow/widower of deceased. (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 ______/______/___________ MM DD YYYY No NOTICE: Petition should be clearly completed (preferably typed) and original mailed to the Bureau at the address in the upper left corner. (OVER) LIBC-386 REV 2-05 (Page 1) 386 0205 American LegalNet, Inc. www.USCourtForms.com 3. By whom was the deceased employed at the time of the disability? (Give name, address, place of business and business address.) (If the deceased employee was not directly employed by the defendant, state by whom he/she was employed, the work on which he/she was engaged, place of work, and the relation between the direct employer and the defendant.) __________________________________________________________________________________________________ __________________________________________________________________________________________________ 4. The death was the result of the following occupational disease, compensable under paragraph ______________________ of Section 108 of the Occupational Disease Act. 5. The deceased employee first became disabled from earning full wages in the employment in which he was employed on ____/____/______ while in the employ of _____________________________________________________________. MM DD YYYY 6. The deceased employee was last exposed in a hazardous occupation to the occupational disease of which he/she died while in the employ of the defendant on ____/____/______ as ____________________________________________________. MM DD YYYY 7. After the date of disability set forth in paragraph 5, the deceased employee was employed as ________________________ __________________________________________________________________________________________________ 8. The deceased employee received aid from the following doctors and/or hospitals: (Give names and addresses. If none, so state.) __________________________________________________________________________________________________ 9. Expenses of the last illness and burial amounted to $____________.______ Amount paid by the employer $____________.______ 10. On the date that the disability began, the average weekly wage of the decedent was $____________.______ 11. Compensation was was not paid to the decedent after the date of disability as follows: __________________________________________________________________________________________________ __________________________________________________________________________________________________ 12. The deceased employee’s disability did did not develop to the point of disablement after exposure of five or more years. If it did, attach a list of all employers for ten years preceding date of disability, with dates each employment began and ended. 13. The claimant set forth the following additional facts which are believed to be important:_____________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ WHEREFORE, the claimant asks that the Workers’ Compensation Judge make an award that the defendant shall pay such compensation as may be due under the Pennsylvania Occupational Disease Act. DATE OF THIS NOTICE: ____/____/_______ MM DD YYYY I hereby certify that a copy of this Petition has been served on the opposing party. _________________________________________________ SIGNATURE OF PETITIONER OR REPRESENTATIVE Petitioner First Name Last Name _______________________________ Signature ______________________________________________ PLEASE ENTER MY APPEARANCE FOR PETITIONER: Attorney Name ___________________________________________________________________________ Firm Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code _______________________________________ Telephone ________________________________________________________________________________ _________ _____________-_______ PA Attorney ID Number (______) _______-________________________ ________________________________ 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. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-386 REV 2-05 (Page 2) American LegalNet, Inc. www.USCourtForms.com