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This is a Ohio form that can be used for Injured Workers within Workers Comp.
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Self-insurers' Agreement as to Compensation on Account of Death Instructions Mail to the nearest district office. Both the employer and claimant must sign this agreement. Employer: Address: Claim number Employee: Dependent claimant: Address: (Name of deceased) (Street and number) (City) Be it remembered that this agreement is entered into by and between employer and dependents under the authority granted employer by the Industrial Commission of Ohio (IC) pursuant to the provisions of Ohio Revised Code (ORC) 4123.35 and in accordance with the Commission's rules governing procedure. These rules are subject to change or modification by BWC and/or the IC. Therefore, we the above named employer and claimant, hereby agree that: 1. Said above named employee was injured/disabled on the ___________ day of _________________ , 20 _____ at __________ M. 2. Injury resulted in the death of said employee on the ___________ day of _________________ , 20 _____ 3. Employee's average weekly wage for the year preceding injury was $ _________________ . 4. The following was dependent upon said employee for support at time of death: Name Age Relationship to Deceased Wholly or Partially 5. The rate compensation the employer will pay to the dependent claimant named above will be $ ___________________ per week for a period of _____________ weeks, beginning on the ___________ day of ______________________ , 20 _____ and continuing until entire amount of the award has been paid out of future facts warrant modification. If under the age of 18 the total amount to be paid out per the above order will be $ ___________________. Dependent claimant should advise the employer if enrolled in a continuing educational program after the age of 18. 6. Said employer has/will pay funeral expenses, etc., in accordance with the provisions of the ORC. 7. Date when first payment has/will be made ___________________ , 20 _____ 8. (Here insert any special articles of agreement not covered by the foregoing.) The foregoing is herewith submitted for approval and confirmation by BWC/ IC, or such other action as they may deem necessary. Date of agreement (Employer) Signed in the presence of By (Dependent) BWC-1177 (Rev. 3/01/05) C-59 American LegalNet, Inc. www.FormsWorkFlow.com