Claim For Compensation For Line Of Duty Compensation Benefits {WCLoD-1A}

WCLoD - 1A (11 - 18) AI 1 Pursuant to the provisions of the Line of Duty Compensation Act, 247287.243, RSMo, as amended, application is hereby made for payment of benefits as follows: 1. Decedent222s Name 2. Decedent222s Social Security Number 3. Address of decedent222s Missouri residence at time of death If no Missouri address, please provide the address of decedent222s residence at time of death 4. Date of death 5. Date of injury resulting in death 6. Employer222s name and address 7. Place of injury causing death 8. Rank and title of position or designation of the position in which decedent was serving at time of death, or at time of injury resulti ng in death 9. Name and address of Personal Representative 10. County where the estate is being probated 11. County which has jurisdiction to probate the estate 12. Decedent222s marital status at time of death 13. (If applicable) name, address, phone number and Social Security Number (last four digits) of decedent222s surviving spouse 14. Did decedent have children? Yes No 15. Please attach copies of the following documents (if available) that provide a full, factual account of the circumstances resulting in or the course of events causing the decedent222s death: A. Report of Casualty or Accident filed with the employer; B. Certificate of Death; C. Police Report; D. Autopsy Report; E. Medical Records; F. Toxicology Report. 16. Please attach copies of the following documents that support this application: A. Certified copy of the Order granting Refusal of Letters to surviving spouse or unmarried minor, minor, or dependent children entered by the Circuit Court; B. Certified copy of the Circuit Court Order on the Determination of Heirship; C. Certified copy of the Circuit Court Order on small estate procedures; D. Certified copy of the Circuit Court Order on Termination of Administration and approval of the final settlement of the estate; E. Court222s Decree of Final Distribution. 17. Please attach copies of any other documents that may be relevant or useful in consideration of this claim. MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS CLAIM FOR COMPENSATION FOR LINE OF DUTY COMPENSATION BENEFITS (Use this form when the worker's death occurred before August 28, 20 3315 West Truman Blvd. P.O. Bo x 58 Jefferson City, MO 65102-0058 573-526- 4941 www.labor.mo.gov/DWC 7) Instructions: 1. Type or print clearly in ink. 2. Claim must be filed by the estate of the deceased. 3. Last page of this form must be signed by claimant and notarized. 4. If question is not applicable, please answer with N/A. 5. Claim may be filed in person at any of the Division222s adjudication offices or by mail at the address indicated above. 6. Claim must be filed within one year of the date of death of a law enforcement officer, emergency medical technician, air ambulance pilot, air ambulance registered professional nurse, or firefighter killed in the line of duty. FOR DIVISION USE ONLY Case Number: Date Received: American LegalNet, Inc. www.FormsWorkFlow.com WCLoD - 2A (11 - 18) AI STATE OF ) ) COUNTY OF ) on oath, states that the information in the foregoing application was completed by, or at the direction of, the undersigned and that matters stated therein are true and correct. Claimant222s Signature Subscribed and sworn to before me this day of , 2 . Notary Seal Notary Public Claimant Information 1. Claimant222s Name 2. Claimant222s Address 3. Telephone Number Home: Work: 4. Relationship to decedent 5. Date of filing claim 6. A Petition for Issuance of Letters of Administration was filed In the Circuit Court of County, Probate Division, Estate Number: 7. A full probate administration was not required based upon the following: A. Refusal of Letters to surviving spouse or unmarried minor, minor, or dependent children ordered by the Circuit Court; B. Determination of Heirship in an intestate case. 8. Name and address of the attorney representing the estate 9. (please check the appropriate box below) I am am not currently represented by an attorney. I agree to notify the Divi sion in writing if and when I hire an attorney to represent me in this case. American LegalNet, Inc. www.FormsWorkFlow.com