Delaware > Workers Compensation
Petition to Determine Compensation Due to Dependents of Deceased Employee - Delaware
| Petition to Determine Compensation Due to Dependents of Deceased Employee Form. This is a Delaware form and can be used in Workers Compensation . |
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PETITION TO DETERMINE COMPENSATION DUE TO DEPENDENTS OF DECEASED EMPLOYEE ________________________ To the Industrial Accident Board of the State of Delaware Sitting in and for County _____________________________________ Claimant vs. _____________________________________________ _____________________________________ Employer } Hearing No. The undersigned petitioner respectfully represents: That the above named claimant and the above named employer have failed to reach an agreement in regards to compensation due said claimant as the dependent of _____________________________________ _____________________________ a deceased employee of said employer. The undersigned therefore prays that your Honorable Board shall, after due notice of the time and place of hearing served on all parties in interest, hear and determine the matter in accordance with the facts and the law and state its conclusions of fact and rulings of law. Dated this _________ day of ____________________________A.D. 20 _____. ___________________________________________ Name ___________________________________________ Address DOCUMENT NO 60-07-82-11-08 -108- American LegalNet, Inc. www.FormsWorkflow.com INDUSTRIAL ACCIDENT BOARD STATE OF DELAWARE ______________________ Statement of Facts Upon Failure to Reach an Acreement (Section 108) 1. Name of employee ___________________________________________________________________ Employee's SS#___________________________ DOB _____________________________ 2. 3. 4. 5. 6. 7. Residence of employee ________________________________________________________________ Date of accident ______________________________________________________________________ Place of accident ______________________________________________________________________ By whom employed at the time of accident ________________________________________________ Occupation of employee at the time of accident ____________________________________________ Nature of accident and how it happened __________________________________________________ ____________________________________________________________________________________________ _____________________________________________________________________________________________ 8. Kind of work being done by employee at time of accident _____________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 9. Describe the nature of injury _____________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 10. Did employee receive medical, surgical or hospital service ____________________________________ _____________________________________________________________________________________________ 11. Did employee request employer to furnish such service _______________________________________ _____________________________________________________________________________________________ 12. 13. Was such service furnished ______________________________________________________________ When was notice of injury given to or received by employer ___________________________________ _____________________________________________________________________________________________ 14. 15. State weekly wages when injured _________________________________________________________ State weekly wages for twelve months before the accident ____________________________________ -109American LegalNet, Inc. www.FormsWorkflow.com 16. 17. State number of weeks employed during said twelve months __________________________________ State at what trade or occupation employed during said twelve months _________________________ _____________________________________________________________________________________________ 18. If employee died as a result of the accident, give date of death _________________________________ _____________________________________________________________________________________________ 19. What were the expenses of last sickness and burial __________________________________________ _____________________________________________________________________________________________ 20. State amount of these expenses paid by the employer _________________________________________ _____________________________________________________________________________________________ 21. Give name of widow or widower of deceased, if dependent ____________________________________ _____________________________________________________________________________________________ 22. Give names and dates of birth of dependent children under sixteen years of age. _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ 23. Give name and address of surviving father and mother of deceased, if dependent. _________________________________________ _________________________________________ ___________________________________________ ___________________________________________ 24. Give names and dates of birth of dependent brothers and sisters of deceased under sixteen years of age. ___________________________________________ ___________________________________________ ___________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ 25. State any other important facts bearing on the case above presented. Dated this __________ day of _________________________________________ Witness: A.D. 20 ____________________ ___________________________________________ Name -110American LegalNet, Inc. www.FormsWorkflow.com
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