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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 at 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 Employers 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. Decedents Social Security Number: ________________________________________________________________________ __ 11. Name(s), Address(es) and Social Security Number(s) of all benefici aries 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. 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) C. Record of Emergency Data (DD Form 93) D. Servicemembers Group Life Insurance Election and Certificate (SGLV8222) 13. Attach copies of any other form(s) on which decedent designated benefi ciaries for receipt of death benefits. Provide Social Security Number of each beneficiary designated. 14. Decedents Marital Status at time of death: ___________________________________________________________________ Printed by authority of the State of Illinois - March 2005 - 500 - CC-92 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 215. (If applicable) Name, Address, Phone Number and Social Security Number of decedent s surviving spouse: ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ 16. Did decedent have children?? Yes ? No 17. (If applicable) Name(s), Address(es), Phone Number(s), Social Se curity Number(s) and Birthdates of decedent s children: ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ 18. Name(s), Address(es), Phone Number(s) and Social Security Number( s) of other parent(s) of child or children listed in 17:________________________________________________________________________ _________________________________ ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ 19. (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: ________________________________________________________________________ ________ ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ ________________________________________________________________________ ____________________________________ 20. (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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