Self-Insurers Agreement As To Compensation On Account Of Death {BWC-1177}

BWC-1177 / C-59 - SELF-INSURERS' AGREEMENT AS TO COMPENSATION ON ACCOUNT OF DEATH. This form is used by employers and dependents of a deceased employee to formalize the compensation arrangement after a worker's death resulting from a work-related injury. The agreement outline the circumstances of the injury and deathm the amount of compensation to be paid to the dependents, the duration of compensation payments, the employer's responsibility for funeral expenses, and any special conditions or terms not covered in the standard agreement. It is submitted for approval to the Bureau of Workers' Compensation or Ohio Industrial Commission. Both the employer and claimant must sign this agreement. www.FormsWorkflow.com