BI-402 06/11 Application for Fatal Dependents’ Benefits Please return this form to: BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV, 25332-3151 In all claims for compensation, except occupational pneumoconiosis or other occupational diseases, the application and proofs of dependency in fatal cases must be filed within six months from and after the employee’s date of death. In occupational pneumoconiosis claims, the application for compensation and proofs of dependency in fatal cases must be filed by the dependents of the employee within two years from and after the employee’s death. In occupational disease claims other than occupational pneumoconiosis, the application for compensation and proofs of dependency in fatal cases must be filed by the dependents of the employee within one year from and after the employee’s death. NOTE: THESE TIMES FOR FILING ARE A CONDITION THAT MUST BE MET OR THE RIGHT TO COMPENSATION WILL BE FOREVER BARRED. ASURVIVING SPOUSE OR GUARDIAN OF CHILDREN APPLYING FOR BENEFITS MUST COMPLETE THESE QUESTIONS. REASON FOR FILING CLAIM DECEASED EMPLOYEE Employee: Employer: Address: Address: City, State, Zip City, State, Zip: Social Security No.: Date of Injury: Date of Death: Date of Birth: I, hereby apply for fatal dependent benefits. My relation to the deceased is (Name of Applicant) Death resulted from: Occupational disease . Occupational injury (Names and address of employer) (Dates worked) (Names and address of employer) (Dates worked) Explain how this injury or disease, suffered in and resulting from employment, was a contributing factor to this death. (If additional space is needed, complete the statement on a separate sheet of paper.) SEE INSTRUCTIONS ON THE BACK OF THIS FORM AND COMPLETE THE APPLICABLE SECTION OR SECTIONS BELOW. Current Address: (include city, state, zip) Social Security Number: What was your name before your marriage to the deceased? Date and place of marriage: Date and place of birth: Driver’s License number and state of issuance: Did you live with the deceased from the date of marriage to the date of death? If no, please explain. Was the deceased ever previously married? If yes, how was the marriage dissolved? Yes Yes No No Were you actually dependent upon the earnings of the deceased at the date of death? Were you pregnant with the deceased’s child at the time of death? If yes, provide expected date of birth: Yes Yes No No THE FOLLOWING MUST BE COMPLETED TO IDENTIFY THE SURVIVING DEPENDENT CHILDREN: Name Social Security Number Date of Birth Full-Time Student Driver’s License Number and State (18-25) or Disabled Child * Please note: Full-time students between the ages of 18 and 25 must complete a student contract application to receive benefits. If you have an invalid child you must provide medical evidence. If any surviving dependent children are not in the immediate care and custody of the surviving spouse, see instructions on reverse side and explain. Also, please list those children in the space provided above. BrickStreet Mutual Insurance P.O. Box 3151  Charleston, WV  25332 THESE QUESTIONS MUST BE ANSWERED BY SURVIVING DEPENDENTS OTHER THAN A SPOUSE OR CHILD. THESE QUESTIONS MUST BE ANSWERED BY PARENTS, GRANDPARENTS, SIBLINGS, ETC. Name Social Security Number Driver’s License Number and State Date of Birth Relationship to Deceased Invalid Medical Evidence Enclosed, Yes or No? Are you aware of any other surviving dependents? If so, please provide as much information as possible about them. Please attach a separate sheet of paper with the above information, if additional space is needed. Were you fully dependent upon the earnings of the deceased at the date of death? Yes No If yes, provide documentation of dependency (i.e., tax returns, proof of health insurance, trustee accounts). Were you partially dependent upon the earning of the deceased at date of death? Did you reside in the same household as the deceased at the date of death? If no, provide current address: Yes No Yes No What weekly amount was contributed to your support by the deceased? $ What was the total amount contributed to your support by the deceased during the 12 months prior to the death? $ Were you incapable of self-support? If yes, why? Yes No Other income: List all amounts and sources (i.e., tax returns, Social Security benefits, Department of Health and Human Resources, pension, disability insurance, etc.) Signature of Applicant Telephone Number Witness Signature Witness Signature Sworn and subscribed before me, the undersigned authority, on the Officer Taking Acknowledgement day of . Date My Commission Expires INSTRUCTIONS IMPORTANT: To avoid delay in considering your claim, be sure to answer all questions that apply and attach the appropriate certificates and documents to your application. Please note that the form must be notarized. Certified copies of the following documents must be submitted where applicable: Death Certificate Autopsy Report Marriage Certificate Divorce Decree Birth Certificate A certified copy of the death certificate showing the cause of death must be submitted. If an autopsy was performed, a complete copy of the autopsy report must be submitted. A certified copy of the marriage certificate must be filed. If either the surviving spouse or the deceased employee was previously married and divorced, a certified copy of the divorce decree must be submitted. If the former marriage dissolved by death, a certified copy of the death certificate must be submitted. If surviving children are to receive benefits, a birth certificate must be submitted for surviving children under 18 years of age. Children under 25 years of age attending school fulltime may qualify for benefits if a statement verifying their attendance is sent to BrickStreet by the registrar of an accredited school. If dependent children are living in a different household from that of the deceased, information must be submitted including their name, date of birth, Social Security number, driver’s license number (if applicable), address and the dependency circumstances involved. Their legal guardian must file an application on behalf of such children and must include a copy of the guardianship appointment. Benefits must be paid for an invalid child if appropriate medical information is filed that proves that the child is an invalid. Other dependents (parents, grandparents, siblings, etc.) must submit proof of dependency, in affidavit form, with their application for compensation. Individuals having knowledge that the applicants were dependent upon the earnings of the deceased for support, and describing the amount of contribution and the dates and methods of contribution should make affidavits. Also, a statement must be filed by the applicant explaining all the amounts and sources of other income. Form BI-400 Services Invoice must be completed to apply for funeral expenses. This form may be downloaded at www.BrickStreet.com, or you may request a printed form by calling the number listed below. If you have any question or need assistance with this form, please contact BrickStreet Mutual Insurance by phone at 1-866-452-7425, or write to P.O. Box 3151 , Charleston, WV 25332. American LegalNet, Inc. www.FormsWorkFlow.com