Application For Adjustment Of Claim In Case Of Death Due To Occupational Disease {BWC-4463}

Application for Adjustment of Claim in Case of Death Due to Occupational Disease Instructions: Youmustfilethisforminduplicateandhave itaccompaniedbyduplicatecopiesoftheproofreliedupon tosupporttheclaim. O.D. (BWCClaimNumber) Employer: Employee: Theabovenamed (Deceased) (EmployerAddress) Beneficiary: (EmployerorBeneficiary) herebygivesnoticetotheOhioBureauofWorkers'Compensation(BWC)thatthepartiesheretohavefailedtoreachan agreementinregardtocompensation,etc.,tobepaidonaccountofthedeathoftheabovenamedemployee;andhereby makesapplicationtoBWCforthepurposeofdeterminingtheamountofcompensation,etc.,tobepaidorfurnishedto saidbeneficiary,orbeneficiaries,inaccordancewiththeprovisionsofSection27oftheWorkers'CompensationAct. Thereasonsfordisagreementareasfollows: Saidapplicant,insupportofsaidapplication,submitsthefollowingstatementoffactsfortheconsiderationofBWC: 1. Whatwasdeceased'sage?____________ Single Married Widowed Divorced 2. Fromwhatdiseasewasdeceasedsuffering? 3. Whatwerethesymptoms? 4. Whendidthesesymptomsfirstappear? 5. Haddeceasedpreviouslysufferedfromthisdisease? 6. Onwhatdaydiddeceasedquitworkonaccountofthedisease? 7. Givedateofdeath_____________Hourofday__________AMPM 8. NameofAttendingPhysician_______________________________Address_________________________________ 9. WhendiddeceasedlastbecomearesidentofOhio? 10. Wasautopsyperformed?...YesNoBywhom? 11. Givethenameandaddressoftheemployeroremployersforwhomdeceasedworkedforninetydayspreceding dateofdeath. 12. Thisapplicationismadeonbehalfoftheabovenamedbeneficiaryandthefollowingnamedpersons,whowere dependentondeceasedforsupport: Name Age Relationship to deceased Wholly or partially 13. Theexpensesbelowhavebeenincurredformedicalandfuneralexpenses,etc.,inconnectionwiththe disabilityanddeathofsaidemployee: Nature of expense Medicalservices:........................................... Hospitalservices: .......................................... . Amount Nature of expense Nursingservices:........................................... Funeral: .......................................................... . Amount BysigningthisapplicationIexpresslywaive,onbehalfofmyselfandofanypersonwhoshallhaveanyinterest inthisclaim,allprovisionsoflawforbiddinganyphysicianorotherpersonwhohasheretoforeattendedorexamined deceasedfromdisclosinganyknowledgeorinformationwhichtheytherebyacquired. Ihavereadallthestatementscontainedhereinandknowthesametobetrueandcorrect. Signed (Applicant) (Address) Datedat____________________________this______dayof________________________________,___________. BWC-4463(Rev.2/25/1999) OD-58-22 American LegalNet, Inc. www.FormsWorkFlow.com