Pennsylvania > Workers Comp
Fatal Claim Petition For Compensation By Dependents For Death Covered By The Pennsylvania Occupational Disease Act LIBC-384 - Pennsylvania
| Fatal Claim Petition For Compensation By Dependents For Death Covered By The Pennsylvania Occupational Disease Act Form. This is a Pennsylvania form and can be used in Workers Comp . |
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FATAL CLAIM PETITION FOR Deceaseds COMMONWEALTH OF PENNSYLVANIA Social Security Number: - -DEPARTMENT OF LABOR AND INDUSTRY COMPENSATION BY BUREAU OF WORKERS COMPENSATION DEPENDENTS FOR DEATH 1171 S. CAMERON STREET, ROOM 103 Date of Injury: / / HARRISBURG, PA 17104-2501 COVERED BY THE MM DD YYYY (TOLL FREE) 800-482-2383 PENNSYLVANIA OCCUPATIONAL PA BWC Claim Number: (IF KNOWN) DISEASE ACT Deceased Employee Employer First Name Last Name Name _______________________________ ____________________________________________________________________________________________________________________ Street 1 ___________________________________________________________________________ Date of Birth ______/______/________ Date of Death ______/______/________ Street 2 MM DD YYYY MM DD YYYY ___________________________________________________________________________Dependent City/Town State Zip Code __________________________________________ __________ __________-_______ First Name Last Name County _______________________________ _________________________________________ _________________________________ Street 1 Telephone FEIN ___________________________________________________________________________ (______) _______-_______________ _________________________ Street 2 ___________________________________________________________________________VS. City/Town State Zip Code Insurer or Third Party Administrator (if self-insured) __________________________________________ __________ __________-_______Name County Telephone ___________________________________________________________________________ ___________________________________________ (______) _______-_______________Street 1 ___________________________________________________________________________Injury Street 2 Description of Injury and Cause of Death ___________________________________________________________________________ City/Town State Zip Code ___________________________________________________________________________ __________________________________________ __________ __________-_______ Telephone Bureau Code ___________________________________________________________________________ (______) _______-_______________ ____________________________ County ___________________________________________________________________________ ______________________________ Claim Number FEIN ___________________________________________________________________________ ______________________________ ___________________________ ___________________________________________________________________________ ___________________________________________________________________________ 1. Death was a result of ? Silicosis ? Anthraco-Silicosis ? Asbestosis 2. The deceased employee has been employed in a hazardous occupation in the Commonwealth of Pennsylvania having a G Silica hazard G Asbestos hazard for at least two years in the aggregate during the ten years preceding disability as follows: NAME OF EMPLOYER IN PENNSYLVANIA ADDRESS DATES OF EMPLOYMENT FROM TO (MM/DD/YYYY) (MM/DD/YYYY)_________________________________________________ _____________________________________________________ ________/________/__________ ________/________/_____________________________________________________________ _____________________________________________________ ________/________/__________ ________/________/_____________________________________________________________ _____________________________________________________ ________/________/__________ ________/________/_____________________________________________________________ _____________________________________________________ ________/________/__________ ________/________/_____________________________________________________________ _____________________________________________________ ________/________/__________ ________/________/____________3. The deceased employee was last engaged in a hazardous occupation having a G Silica hazard G Asbestos hazard in the employ of the defendant on _____/_____/_________. MM DD YYYY 4. The deceased employee became totally disabled on _____/_____/_________. MM DD YYYY LIBC-384 REV 4-04 (Page 1) (OVER) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 5. The deceased employee received aid from the following doctors and/or hospitals: (Give names and addresses. If none, so state.) __________________________________________________________________________________________________ __________________________________________________________________________________________________ 6. Expenses of the last illness and burial amounted to $__________._____ Amount paid by the employer $__________._____ 7. The average weekly wage of the deceased employee in the employ of the defendant employer was $________._____. 8. Was compensation paid to the deceased employee between the time total disability began and the date of his/her death? G Yes G No If Yes, payments began on ____/____/______ MM DD YYYY 9. Dependents of the deceased employee are as follows: NAME RESIDENT DATE OF BIRTH RELATIONSHIP (MM/DD/YYYY) _________________________________________________ _____________________________________________________ ________/________/__________ ______________________________________________________________________________ _____________________________________________________ ________/________/__________ ______________________________________________________________________________ _____________________________________________________ ________/________/__________ ______________________________________________________________________________ _____________________________________________________ ________/________/__________ ______________________________________________________________________________ _____________________________________________________ ________/________/__________ _____________________________10. The petitioner G is G is not a widow/widower of the deceased. a. If petitioner is a widow or widower, state where ceremony was performed and give date of marriage. _______________________________________________________________________ _____/_____/______ MM DD YYYY b. Was marriage a common law marriage? G Yes G No 11. The claimant has provided the following additional information: ________________________________________________ __________________________________________________________________________________________________ ___________________________________________________
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