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Last updated: 11/25/2025
Claim For Dependents Benefits (Fatality)
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Description
CLAIM FOR DEPENDENT BENEFITS. This form is issued by the Industrial Commission of Arizona (ICA) for dependents of a worker who has died as a result of a work-related injury or illness. This form allows eligible individuals—such as a spouse, dependent children, parents, or other dependents—to apply for workers’ compensation death benefits or reimbursement of burial expenses. Applicants must provide a certified death certificate, marriage and/or birth certificates, and details about the deceased’s employment and cause of death. The form collects information on the claimant’s relationship to the deceased, dependency status, and supporting documentation. Completed forms are filed with the ICA’s Phoenix or Tucson offices for review and processing. www.FormsWorkflow.com
