Texas > Workers Compensation > Employee
Beneficiary Claim For Death Benefits DWC-42 - Texas
| Beneficiary Claim For Death Benefits Form. This is a Texas form and can be used in Employee Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
DWC042 Texas Department of Insurance Division of Workers' Compensation Records Processing 7551 Metro Center Drive, Suite100 · MS-94 Austin, TX 78744-1645 (800) 252-7031 phone · (512) 804-4378 fax Complete if known: DWC Claim # Carrier Claim # Beneficiary Claim for Death Benefits I. DECEASED EMPLOYEE INFORMATION Name (First, Middle, Last ) Address at time of death (Street, City, State, Zip) Race / Ethnicity White, not of Hispanic origin Social Security Number (if known) Black, not of Hispanic origin Hispanic Asian or Pacific Islander II. INJURY INFORMATION Death occurred as a result of an Date of death (mm/dd/yyyy) Date of injury (mm/dd/yyyy) injury occupational disease Provide a description of the circumstances and nature of the injury or occupational disease (if known) III. EMPLOYER INFORMATION Company name Phone number Address (Street, City, State, Zip) Supervisor's name (First, Last) IV. INFORMATION ABOUT PERSON COMPLETING THIS FORM Name (First, Middle, Last) Check all appropriate box(es) that apply to indicate your status regarding this claim: 1. Eligible beneficiary (complete Part VII. if applicable) Eligible non-dependent parent (complete Part V.; complete Part VII. if applicable) 2. 3. Filing on behalf of someone else (complete Part VI.; complete Part VII. if applicable) If you checked box 1 or 2, enter your: Social Security Number and Date of birth Address (Street, City, State, Zip) Phone number Relationship to deceased (mm/dd/yyyy) V. ELIGIBLE NON-DEPENDENT PARENT INFORMATION If you are claiming death benefits as an eligible non-dependent parent (see Frequently Asked Questions for definition) and the date of injury shown in item II above is between September 1, 2007 and August 31, 2009, you are not eligible unless you also claim and receive burial benefits. If this applies to you, indicate the status of your claim for burial benefits by checking the appropriate box: 1. Received from the insurance carrier (attach proof) 2. Pending with insurance carrier Filed at the same time as the claim for death benefits 3. NOTE: For injuries that occurred prior to September 1, 2007, non-dependent parents are not eligible to claim death benefits. For injuries that occurred after August 31, 2009, eligible non-dependent parents are not required to claim and receive burial benefits in order to claim death benefits. DWC042 Rev. 04/10 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com DWC042 IMPORTANT: Before completing this page, please read WHO MAY BE AN ELIGIBLE BENEFICIARY? in the Frequently Asked Questions section on page 3 of this form. Yes No If yes, complete this section. VI. ARE YOU FILING THIS CLAIM ON BEHALF OF OTHER BENEFICIARIES? A claim by an eligible non-dependent parent must designate all eligible non-dependent parents. List here or in Section VII. as applicable. (Attach additional pages, if needed) Beneficiary's name (First, Middle, Last) Address (Street, City, State, Zip) Phone number Date of birth (mm/dd/yyyy) Is this beneficiary a minor? Name Address (Street, City, State, Zip) Phone number Yes No Full-time student Yes No Social Security Number Relationship to deceased If yes, provide the following information for the minor's parent or legal guardian: Beneficiary's name (First, Middle, Last) Address (Street, City, State, Zip) Phone number Date of birth (mm/dd/yyyy) Is this beneficiary a minor? Name Address (Street, City, State, Zip) Phone number Yes No Social Security Number Full-time student Yes No Relationship to deceased If yes, provide the following information for the minor's parent or legal guardian: Beneficiary's name (First, Middle, Last) Address (Street, City, State, Zip) Phone number Date of birth (mm/dd/yyyy) Is this beneficiary a minor? Name Address (Street, City, State, Zip) Phone number Yes No Social Security Number Full-time student Yes No Relationship to deceased If yes, provide the following information for the minor's parent or legal guardian: VII. ARE YOU AWARE OF ANY OTHER BENEFICIARIES? (Attach additional pages, if needed) Beneficiary's name (First, Middle, Last) Address (Street, City, State, Zip) Beneficiary's name (First, Middle, Last) Address (Street, City, State, Zip) Beneficiary's name (First, Middle, Last) Address (Street, City, State, Zip) Yes No If yes, complete this section. Relationship to the deceased Phone number Relationship to the deceased Phone number Relationship to the deceased Phone number Signature of beneficiary or person completing this form on behalf of beneficiary Date NOTE: With few exceptions, upon your request, you are entitled to be informed about the information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). DWC042 Rev. 04/10 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com DWC042 Frequently Asked Questions Beneficiary Claim for Death Benefits (DWC Form-042) Who can file a claim for death benefits? Beneficiaries of an employee who died from a work-related injury or occupational illness may file a claim for workers' compensation death benefits. Each person must file a separate claim for death benefits unless the claim expressly includes or is made on behalf of another person (for example, a spouse filing a claim that includes minor children, or an eligible parent filing a claim that includes another eligible parent). Who may be an eligible beneficiary? · the deceased employee's spouse · the deceased employee's children (i.e., minor children, children who are full-time students younger than 25, dependent stepchildren, or other dependent children) · deceased employee's dependent grandchild if the grandchild's parent is not an eligible child · other dependents of the deceased employee (i.e., dependent adult children with disabilities, parents, adoptive parents, stepparents, siblings, or grandparents) If you are a non-dependent parent, you may be eligible to receive death benefits under the following circumstances: · there are no eligible surviving beneficiaries in the categories listed above; · you are the mother, father, adoptive parent, or stepparent of the deceased employee and your parental rights have not been terminated; and, · the employee's injury occurred on or after September 1, 2009; or, · the employee's injury occurred between September 1, 2007 and August 31, 2009 and you have received burial benefits under the Texas Workers' Compensation Act. NOTE: If you
|
|||||||
