Form OIC-WC-201 West Virginia Workers' Compensation Application for Fatal Dependents' Benefits 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. Section I Employee: Address: City, State, Zip: Social Security No: Date of Death: / / - Deceased Employee Information Employer: Address: City, State, Zip: Date of Injury: Date of Birth: / / / / Section II I, _ (Name of Applicant) Reason for Filing Claim _________________________ ____________________ hereby apply for fatal dependents' benefits. My relation to the deceased is: _ Occupational Injury Occupational Disease Dates Worked: Dates Worked: Death resulted from: Name, Address of Employer: Name, Address of Employer: 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 this statement on a separate piece of paper). Section III Dependents' Information ­ Please See Instructions on the Back of This Form TO BE COMPLETED BY SURVIVING SPOUSE: Social Security No.: Date and Place of Marriage: / / Current Address (Include City, State, Zip): What was your name before marriage to the deceased? Date and Place of Birth: / / Driver's License Number and State of Issuance: Yes No 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: Were you actually dependent on the earnings of the deceased at the date of death? Were you pregnant with the deceased's child at the time of death? Yes No Yes No Yes No / / If yes, provide expected birth date: PLEASE IDENTIFY ALL SURVIVING DEPENDENT CHILDREN ­ TO BE COMPLETED BY SURVIVING SPOUSE OR GUARDIAN: Name Social Security No. Date of Birth / / / / / / / / Full Time Student Driver's License No. and State 18-25 or Disabled? 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. American LegalNet, Inc. www.FormsWorkFlow.com Rev. 1/11 PLEASE IDENTIFY ALL SURVIVING DEPENDENTS OTHER THAN A SPOUSE OR CHILD (SIBLINGS, PARENTS, GRANDPARENTS, ETC.): Name Social Security No. - Date of Birth / / / / / / Driver's License No. and State Relationship to Deceased Medical Evidence of Invalidism Enclosed? Are you aware of any other surviving dependents? If so, please provide as much information as possible about them: 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, etc.) Were you partially dependent upon the earnings of the deceased at the date of death? Did you reside in the same household as the deceased at the date of death? If no, provide current address: Yes Yes No No What weekly amount was contributed to your support by the deceased at the date of death? $ Were you incapable of self-support? If yes, why? Yes No Other Income: List all amounts and sources and provide documentation: Signature of Applicant: Telephone Number: ( ) - Signature of Witness Signature of Witness: Sworn and subscribed before me, the undersigned authority, on the __________ day of ____________________________________, ____________ Officer Taking Acknowledgment: 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 full-time may qualify for benefits if a statement verifying their attendance is sent to your insurance carrier 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