Illinois > Secretary Of State > Court Of Claims
Illinois National Guardsmans And Naval Militiamens Compensation Act Form - Illinois
| Illinois National Guardsmans And Naval Militiamens Compensation Act Form Form. This is a Illinois form and can be used in Court Of Claims Secretary Of State . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Illinois Court of Claims Office of the Secretary of State 630 S. College St., Springfield, IL 62756 Illinois National Guardsmens and Naval Militiamen s Compensation Act Form Pursuant to provisions of the Illinois National Guardsmens and Navel Militiamen s Compensation Act, applicationis hereby made for payment of benefits to the death of: 1. Name of Illinois National Guard or Navy Militia Member:_____________________________________________________ 2. Address at Death: ________________________________________________________________________ ___________________ 3. Date of Death: ________________________________________________________________________ ______________________ 4. Date of Injury Resulting in Death: ________________________________________________________________________ ___ 5. Unit Address: ________________________________________________________________________ ______________________ ________________________________________________________________________ ____________________________________ 6. Rank and assignment in which decedent was serving at time of death or at time of injury resulting in death: ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ 7. Social Security Number: ________________________________________________________________________ ____________ 8. Name(s), Address(es) and Social Security Numbers of all beneficiarie s designated by decedent for receipt of benefits. Name Address Social Security Number $ amount or % share ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ 9. (If no beneficiary designation) Name and Address of personal represent ative of decedents estate (administrator, executor), Date of Appointment, Court Appointing and Probate File Number: ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ 10. (If no beneficiary designation) Names and Addresses of decedents heirs or next-of-kin: ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ 11. Statement of circumstances resulting in or the events causing the death of the Illinois National Guard or Navy Militia Member (newspaper accounts, death certificate, coroners certificate or other documentation may be attached, if available): ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ (If more space is needed, please attach additional sheets.) Printed by authority of the State of Illinois - March 2005 - 500 - CC-89 American LegalNet, Inc. www.USCourtForms.com
|
|||||||
