Michigan > Workers Comp
Death Benefit Stipulation WLK-135 - Michigan
| Death Benefit Stipulation Form. This is a Michigan form and can be used in Workers Comp . |
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Department of Workforce Development Workers Compensation Division DEATH BENEFIT STIPULATION 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, Wl 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://www.dwd.state.wi.us/wc/ e-mail: DWDDWC@dwd.state.wi.usDepartment of Workforce Development WC Claim Number Deceased Employee Name Employee Social Security Number Applicant Mailing Address City State Zip Code Injury Date Employer Name Employer Mailing Address City State Zip Code Insurance Company Name insurance Company Mailing Address City State Zip Code vs. Applicant Respondent Insurance Company The parties stipulate the following facts for a Department of Workforce Development award: Date respondent employer and employee were subject Date of Employee Death to Wisconsin Workers Compensation Act: Average Weekly Wage Total Earnings for Year Prior to Injury Compensation Paid $ $ $ Death Benefit Paid Burial Expense Amount of Burial Expense Paid by Respondents $ $ $ The applicant is the surviving spouse of the deceased and was living with the deceased at the time of injury and death. Location of Marriage Date of Marriage Applicant was previously married: Yes No Applicant had children from previous marriage: Yes No Respondents are relying upon the applicants statement confirming his or her relationship to the deceased and children of the deceased. Note: If applicant is a widow, she must use her first or given name when signing the stipulation. Applicant Signature Date Signed Witness: Insurance Company Representative or Self-Insured Employer Signature WKC-135 (R. 07/2001)
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