Pennsylvania > Workers Comp
Fatal Claim Petition For Compensation By Dependents Of Deceased Employees LIBC-363 - Pennsylvania
| Fatal Claim Petition For Compensation By Dependents Of Deceased Employees Form. This is a Pennsylvania form and can be used in Workers Comp . |
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Deceaseds COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY FATAL CLAIM PETITION FOR Social Security Number: - -BUREAU OF WORKERS COMPENSATION COMPENSATION BY 1171 S. CAMERON STREET, ROOM 103 Date of Injury: / / HARRISBURG, PA 17104-2501 DEPENDENTS OF MM DD YYYY (TOLL FREE) 800-482-2383 DECEASED EMPLOYEES TTY 800-362-4228 PA BWC Claim Number: (IF KNOWN)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) __________________________________________ __________ __________-_______ County TelephoneName ___________________________________________ (______) _______-__________________________________________________________________________________________ Street 1 Injury ___________________________________________________________________________ Description of Injury and Cause of Death Street 2 ___________________________________________________________________________ ___________________________________________________________________________ City/Town State Zip Code __________________________________________ __________ __________-_______ ___________________________________________________________________________ Telephone Bureau Code (______) _______-_______________ ______________________________ ___________________________________________________________________________ County ______________________________ ___________________________________________________________________________ Claim Number FEIN ____________________________________________ Check if Occupational Disease ______________________________ ______________________________The petitioner respectfully alleges that: 1. Business of employer _______________________________________________________________________ 2. Time of injury (hour) ______________ AM PM 3. The cause of death was ___________________________________________ as given by ________________ _________________________________________________________________________________________ 4. The deceased employee received aid from the following doctors and/or hospitals: _________________________________________________________________________________________ GIVE NAMES AND ADDRESSES. IF NONE, SO STATE. 5. Expenses of the last illness and burial amounted to $_____________.______ Amount paid by employer $_____________.______ 6. The wages of deceased at the time of accident were $_____________.____ G hour G day G week NOTICE: Petition should be clearly completed (preferably typed) and original mailed to the Bureau at the address in the upper left corner. (OVER) LIBC-363 REV 6-04 (Page 1) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 7. Notice of injury and/or death was given to employer on ____/____/______ by ____________________________________ MM DD YYYY NAME OF PERSON REPORTING INJURY/DEATH in the following manner _______________________________________________________________________________ STATE WHEN AND TO WHOM NOTICE WAS GIVEN AND IN WHAT MANNER. 8. Compensation for disability was paid to the deceased employee from ____/____/______ to ____/____/______. MM DD YYYY MM DD YYYY Total amount paid was $_____________.______ 9. Dependents are as follows: NAME RESIDENCE DATE OF BIRTH RELATIONSHIP (MM/DD/YYYY) _________________________________________________ _____________________________________________________ ________/________/__________ ______________________________________________________________________________ _____________________________________________________ ________/________/__________ ______________________________________________________________________________ _____________________________________________________ ________/________/__________ ______________________________________________________________________________ _____________________________________________________ ________/________/__________ ______________________________________________________________________________ _____________________________________________________ ________/________/__________ _____________________________10. Their dependency is G Total G Partial 11. Petitioner G was G was not living with the deceased at the time of his or her death. 12. 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 13. Other facts which I believe to be important are _____________________________________________________________ __________________________________________________________________________________________________ WHEREFORE, the Petitioner(s) asks that the Bureau shall make an award in accordance with the Pennsylvania Workers Compensation Act. DATE OF THIS NOTICE: ____/____/_______ PLEASE ENTER MY APPEARANCE FOR PETITIONER: MM DD YYYY Attorney A copy of this petition has been sent to the defendant. Name Signature ___________________________________________________________________________ Firm Name _________________________________________________ ___________________________________________________________________________ Street 1 Dependent ___________________________________________________________________________ Street 2 First Name Last Name ___________________________________________________________________________ _______________________________ ______________________________________________City/Town State Zip Code S
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