DECEASED EMPLOYEE DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION SUPPLEMENTAL AGREEMENT FOR002 COMPENSATION FOR DEATH002 DECEASED222S SOCIAL SECURITY NUMBER OR WC ID NUMBER DEPENDENT/GUARDIAN/PERSONAL REPRESENTATIVE DATE OF INJURY WCAIS CLAIM NUMBER -- -- MM DD YYYY EMPLOYER --MM DD YYYY --MM DD YYYY 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 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 employee. 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, are parties to a compensation agreement or award which is changed because on --MM DD YYYY the dependent, Died Remarried A posthumous child was born Other American LegalNet, Inc. www.FormsWorkFlow.com It is now agreed that compensation shall be payable as follows: FROM THROUGH WEEKLY RATE MM-DD-YYYY MM-DD-YYYY #WEEKS/#DAYS REASON FOR CHANGE AMOUNT $ $002 $002 $002 $002 $002 $002 $002 $002 $002 $002 $002 $002 $ - - - -The above compensation shall be payable from to . MM DD YYYY MM DD YYYY Further matters agreed upon: Date of this agreement -- MM DD YYYY Dependent/Guardian/Personal Representative222s signature Claims Representative222s name (typed/printed) Claims Representative222s signature Telephone . Employer Information Claims Information Services Email Services Hearing Impaired *339*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com