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Authorization For Compensation For Death 14 WCA - New Hampshire

Authorization For Compensation For Death Form. This is a New Hampshire form and can be used in General Workers Comp .
 Fillable pdf Last Modified 4/11/2005
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LAB 500 THE STATE OF NEW HAMPSHIRE DEPARTMENT OF LABOR CONCORD, NH 03301 INSURANCE CARRIER DATE AUTHORIZATION FOR COMPENSATION FOR DEATH BENEFICIARY/GUARDIAN NAME ADDRESS DECEASED WORKER EMPLOYERS'S NAME DATE OF INJURY AVG.WEEKLY WAGE SOCIAL SECURITY # FEDERAL IDENTIFICATION # DATE OF DEATH TOT WKLY COMP TO DEPENDENT(S) Chapter 281-A, as amended, Sec 26, Par. I. In all cases where compensation is payable to a widow or widower for the benefit of herself or himself and dependent child or children, the Labor Commissioner shall have power to determine, from time to time, in his discretion what portion of the compensation shall be applied for the benefit of any such child or children and may order same paid to guardian. ALLOCATION OF AWARD TO DEPENDENTS ORIGINAL__SUBSEQUENT DEPENDENT NAME DATE OF BIRTH RELATIONSHIP AMOUNT EXPLANATION OF LUMP SUM SETTLEMENT (IF APPLICABLE) LABOR COMMISSIONER COMPENSATION ANNUALLY ACCOUNTABLE 14 WCA (10/2001) American LegalNet, Inc. www.FormsWorkFlow.com
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