Application For Dependents Benefits And Or Burial Benefits (Occupational Disease Claim) {027}

Form 027 5/24/16 State of Utah - Labor Commission Adjudication.Division 160 East 300 South, 3rd Floor, P.O. Box 146615 Salt Lake City, Utah 84114-6615 (801) 530-6800 casefiling@utah.gov Note: PLEASE TYPE OR PRINT IN BLACK INK ___________________________________________________________ Petitioner ___________________________________________________________ Decedent vs. ___________________________________________________________ Respondent (employer) ___________________________________________________________ Respondent's mailing address ___________________________________________________________ City, State and Zip Code ___________________________________________________________ Respondent's phone number ___________________________________________________________ Respondent's workers' comp Insurance Carrier ___________________________________________________________ Insurance Carrier's mailing address ___________________________________________________________ City, State and Zip Code ___________________________________________________________ Insurance Carrier's phone number APPLICATION FOR HEARING-DEPENDENT'S BENEFITS and/or BURIAL BENEFITS Occupational Disease Claim If deceased employee was employed for less than one year at his/her last employer where the injurious exposure occurred, you must file a separate Application for Hearing for each previous employer where employee suffered an injurious exposure. (NOTE: Include all supporting documentation when this form is filed with the Labor Commission or the Application for Hearing may be returned) I request to have a Claims Resolution Conference scheduled to resolve the issues checked below YES NO PETITIONER UNDER TITLE 34A APPLIES FOR DEPENDENT'S BENEFITS and/or BURIAL ALLOWANCE, AND ALLEGES: 1. The decedent died by occupational exposure arising out of and in the course of decedent's employment with the above named employer, which occupational exposure occurred from Month_________Date______Year_______ to Month ______ Date _____ Year ______ The occupational exposure occurred at the following location: ____________________________________________________________________________________________________ The occupational exposure resulted from either the following repetitive work activities, or harmful substances: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ The cause of death was: ________________________________________________________________________ 2. 3. 4. American LegalNet, Inc. www.FormsWorkFlow.com Form 027 3/1/12 5. 6. The decedent's date of death was: Month______________Date_______Year_____________________. At the time of the occupational exposure at issue: the decedent's wage was $___________per_________, and decedent was working _______hours per week. Decedent was______was not______married and had _________dependent children. The decedent had the following dependents at the time of the occupational exposure at issue: NAME RELATIONSHIP BIRTH DATE PRESENT ADDRESS SOCIAL SECURITY NUMBER 7. Petitioner verifies that the above information is true and correct to the best of petitioner's information and belief. ______________________________________________ _____________ Printed Name of Attorney for Petitioner State Bar # ______________________________________________________________ Signature of Attorney for Petitioner ______________________________________________________________ Mailing Address for Attorney for Petitioner ______________________________________________________________ City/State/Zip Code ______________________________________________________________ Telephone Number _________________________ __________________________________ FAX E-Mail Address ______________________________________ ____________________ Signature of Petitioner Date _____________________________________________________________ Mailing Address of Petitioner _____________________________________________________________ City/State/Zip Code _____________________________________________________________ Petitioner's Telephone Number _____________________________________________________________ Petitioner's Social Security Number _____________________________________________________________ Petitioner's E-Mail Address American LegalNet, Inc. www.FormsWorkFlow.com Form 027 3/1/12 DOCUMENTS THAT MUST BE FILED WITH APPLICATION FOR HEARING IMPORTANT: Failure to include completed and signed forms with all requested supporting documentation will result in the Application for Hearing being returned for completion. If the returned Application for Hearing is not completed and re-filed with the requested supporting documents within sixty (60) days, the Application for Hearing will be dismissed. 1. 2. 3. 4. Decedent's Death Certificate. Documents supporting dependency relationship with the decedent. Minor Dependents' birth certificates. Guardianship or Conservatorship Documents for Petitioner. (Only required if filing on behalf of minor children other than petitioner's own children). If you know the name and address of the adjuster or third party administrator that you have dealt with concerning your claim please include that information: _________________________________________________________________________ Name of adjuster or third party administrator _________________________________________________________________________ Mailing Address for adjuster or third party administrator _________________________________________________________________________ City/State/Zip Code _________________________________________________________________________ E-mail Address American LegalNet, Inc. www.FormsWorkFlow.com