Pennsylvania > Workers Comp
Fatal Claim Petition For Compensation By Dependents For Death Resulting From Occupational Disease LIBC-386 - Pennsylvania
| Fatal Claim Petition For Compensation By Dependents For Death Resulting From Occupational Disease Form. This is a Pennsylvania form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
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 FATAL CLAIM PETITION FOR COMPENSATION BY DEPENDENTS FOR DEATH RESULTING FROM OCCUPATIONAL DISEASE Deceased's Social Security Number: Date of Injury: MM / DD YYYY - / PA BWC Claim Number: Employer (Not to be used where death results from silicosis, anthraco-silicosis and asbestosis. (IF KNOWN) Deceased Employee First Name _______________________________ Last Name _________________________________________ Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County _________________________________ Telephone __________ __________-_______ Date of Birth ______/______/__________ MM DD YYYY Date of Death ______/______/__________ MM DD YYYY Dependent First Name _______________________________ Street 1 Last Name _________________________________________ FEIN ______________________________ ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County __________ Telephone __________-_______ VS. (______) _______-__________________ Insurer or Third Party Administrator (if self-insured) Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-__________________ County _________________________________ Claim Number _________________________________ __________ Bureau Code __________-_______ ___________________________________________ (______) _______-_______________ Injury Description of Injury and Cause of Death ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ______________________________ FEIN ______________________________ The petitioner respectfully alleges that: 1. Dependents of the deceased employee are as follows: NAME _ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ RESIDENCE _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ DATE OF BIRTH (MM/DD/YYYY) ________/________/__________ ________/________/__________ ________/________/__________ ________/________/__________ ________/________/__________ RELATIONSHIP ________/________/____________ ________/________/____________ ________/________/____________ ________/________/____________ ________/________/____________ 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 No ______/______/___________ MM DD YYYY 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 ____________________________________________________. 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: MM DD YYYY __________________________________________________________________________________________________ __________________________________________________________________________________________________ 12. The deceased employee's disability did did not develop to the point of disablement after exposure of five or mor
|
|||||||
