Ohio > Workers Comp > Injured Workers

Annual Death Benefits Questionnaire BWC-1158 - Ohio

Annual Death Benefits Questionnaire Form. This is a Ohio form and can be used in Injured Workers Workers Comp .
 Fillable pdf Last Modified 1/13/2011
Get this form for FREE as a print-only pdf

Annual Death Benefits Questionnaire · BWCrecordsindicateyouarereceivingdeathbenefitsfortheclaimnumberlisted. · Pleasesupplyrequestedinformationandreturnintheenvelopeprovided. · Ifyouhavequestions,pleasecontacttheclaimsservicespecialist(CSS)listedbelow. Nameofdeceasedworker Nameof Address City dependent, survivingspouse, guardian, other Dateofbirth Date Claimnumber SocialSecuritynumber Telephonenumber ZIPcode () State 1. Isthisyourcurrentnameandaddress? Yes No 2. Ifno,pleaseprovidethecorrectnameand/oraddress. Name Address City State ZIPcode TobecompletedbysurvivingspouseONLY: 3. Haveyouremarried? Yes No 4. Ifyes,completefollowinginformation.Ifno,gotoquestion5. Dateofmarriage County State 5. Tobecompletedbysurvivingspouseorguardian.Pleaseverify/completethefollowinginformationforanydependents receivingdeathbenefits.Ifyouneedadditionalspace,pleaseusethebackofthisform. Name of dependents Age Date of birth Social Security number Status of dependent full-time student/disability IcertifyIhaveanswered/verifiedtheabovequestionstruthfullyandcompletely. Signatureof dependent, survivingspouse, guardian, other Date CSSname Serviceofficeaddress City,State,ZIPcode Telephone Fax Iunderstandthatanypersonwhoknowinglymakesafalsestatement,misrepresentation,concealmentoffactoranyother actoffraudtoobtainbenefits/compensationasprovidedbyBWCorself-insuringemployers,orwhoknowinglyaccepts compensationtowhichthatpersonisnotentitled,issubjecttocriminalprosecutionandmay,underappropriatecriminal provisions,bepunishedbyafineorimprisonmentorboth. BWC-1158 (Rev. 9/22/2010) C-39 American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document
URL
Embed


Popular Searches

  1. petition for termination of parental rights
  2. name change
  3. adoption
  4. lien
  5. financial affidavit
  6. dissolution of marriage
  7. civil cover sheet
  8. writ of execution
  9. visitation
  10. dismissal

Bookmark and Share