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Application For Death Benefits Pursuant To Line Of Duty Compensation Act CC-92 - Illinois

Application For Death Benefits Pursuant To Line Of Duty Compensation Act Form. This is a Illinois form and can be used in Court Of Claims Secretary Of State .
 Fillable pdf Last Modified 1/26/2010
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Illinois Court of Claims Secretary of State Illinois Court of Claims, 630 S. College St., Springfield, IL 62756 Application for Death Benefits Pursuant to Line of Duty Compensation Act Pursuant to provisions of the Line of Duty Compensation Act, application is hereby made for payment of benefits on account of the death of: ____________________________________________________________________________________ 1. Name of Decedent: _________________________________________________________________________________________ 2. Address of decedent's Illinois residence at time of death: _____________________________________________________ 3. Address at Time of Entry into the U.S. Armed Forces (if on active duty as an Armed Forces member): _______________ ____________________________________________________________________________________________________________ 4. Place of Birth: ______________________________________________________________________________________________ 5. Date of Death: ______________________________________________________________________________________________ 6. Date of Injury Resulting in Death: ___________________________________________________________________________ 7. Branch of Service (if on active duty as an Armed Forces member):_____________________________________________ 8. Employer and Employer's Address (if not an Armed Forces member): _______________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 9. Rank and Title of Position or assignment in which decedent was serving at time of death or at time of injury resulting in death: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 10. Decedent's Social Security Number: __________________________________________________________________________ 11. Name(s), Address(es) and Social Security Number(s) of all beneficiaries designated by decedent on Line of Duty Compensation Act Designation of Beneficiary Form for receipt of benefits: Name Address Social Security Number $ amount or % share ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 12. Attach a copy of Line of Duty Designation of Beneficiary form: _______________________________________ 13. For claims on deaths of Armed Forces members on active duty, attach copies of the following Department of Defense documents (if available): A. Report of Casualty (DD Form 1300) B. Certificate of Death (DD form 2064) (if available) C. Record of Emergency Data (DD Form 93) (if available) D. Servicemember's Group Life Insurance Election and Certificate (SGLV8222) 14. If the decedent left a will, please attach a copy of it. Provide social security numbers and current addresses of every beneficiary designated in the will. Printed by authority of the State of Illinois. July 2016 -- CC 92.3 American LegalNet, Inc. www.FormsWorkFlow.com 15. Attach copies of any other form(s) on which decedent designated beneficiaries for receipt of death benefits. Provide Social Security Number of each beneficiary designated. 16. Decedent's Marital Status at time of death: ___________________________________________________________________ 17. (If applicable) Name, Address, Phone Number and Social Security Number of decedent's surviving spouse: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 18. Did decedent have children? K Yes K No 19. (If applicable) Name(s), Address(es), Phone Number(s), Social Security Number(s) and Birthdates of decedent's children: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 20. Name(s), Address(es), Phone Number(s) and Social Security Number(s) of other parent(s) of child or children listed in 17:_________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 21. (If decedent left no surviving spouse or children) Name(s), Address(es), Phone Number(s) and Social Security Number(s) of decedent's surviving parents: ________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 22. (If decedent left no surviving spouse, children or parents) Name(s), Address(es), Phone Number(s) and Social Security Number(s) of decedent's next-of-kin and relationship to decedent: _______________________________________________ _________________________________________________
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