Ohio > Workers Comp > Injured Workers
Additional Information For Death Benefits BWC-1108 - Ohio
| Additional Information For Death Benefits Form. This is a Ohio form and can be used in Injured Workers Workers Comp . |
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Additional Information for Death Benefits Instructions Do not use red ink. Supporting documents required Name Social Security number Relationship to deceased Wholly Dependency Partially Date of birth Name Weekly Amount Contributed by Deceased Date of Last contribution Other weekly income Name Amount of payment Date of payment Provider/risk number C-5 American LegalNet, Inc. www.FormsWorkFlow.com
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