CLAIM FOR DEPENDENT BENEFITS

(Workers' Compensation - Dependency Status Declaration)

PART 1: CLAIM INFORMATION

CASE/CLAIM NUMBER: [NUMBER]

DATE OF CLAIM: [DATE]

DECEASED WORKER: [NAME]

DATE OF DEATH: [DATE]

DATE OF INJURY: [DATE]

PART 2: CLAIMANT (DEPENDENT) INFORMATION

2.1 Claimant Identification

Full Legal Name: [FULL NAME]

Date of Birth: [DATE]

Social Security Number: [XXX-XX-XXXX]

Current Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE NUMBER]

Email: [EMAIL]

2.2 Relationship to Deceased

Relationship:
☐ Spouse
☐ Domestic Partner
☐ Child (biological)
☐ Child (adopted)
☐ Child (stepchild)
☐ Child (born after death)
☐ Parent
☐ Sibling
☐ Grandchild
☐ Other: [SPECIFY]

PART 3: TYPE OF DEPENDENCY CLAIMED

3.1 Dependency Classification

I claim dependency status as:

☐ PRESUMPTIVE (TOTAL) DEPENDENT

Basis for presumptive dependency:
☐ I am the surviving spouse and was living with the deceased
☐ I am a minor child (under 18) of the deceased
☐ I am an adult child who is physically or mentally incapacitated
☐ I am an adult child enrolled full-time in school (under age [STATE LIMIT])
☐ Other: [SPECIFY]

☐ PARTIAL DEPENDENT
I was partially dependent on the deceased for financial support.

☐ DEPENDENT-IN-FACT
I was actually and wholly dependent on the deceased for financial support, but I am not a presumptive dependent.

PART 4: SPOUSAL DEPENDENCY INFORMATION

4.1 Marriage/Partnership Information

Date of Marriage/Partnership: [DATE]

Place of Marriage/Partnership: [CITY, STATE/COUNTRY]

Certificate Number: [NUMBER]

Was this a legal marriage/registered domestic partnership? ☐ Yes ☐ No

4.2 Living Arrangement

Were you living with the deceased at the time of death?
☐ Yes - Address: [ADDRESS]
☐ No - Explain: [REASON FOR LIVING APART]

How long did you live together? [DURATION]

If living apart, did deceased provide regular financial support?
☐ Yes - Amount: $[AMOUNT] per [PERIOD]
☐ No

4.3 Prior Marriages

Was either party previously married?
☐ No
☐ Yes - Provide details:

Deceased's prior marriage(s):
| Former Spouse | Date Married | Date Ended | How Ended |
|--------------|--------------|------------|-----------|
| [NAME] | [DATE] | [DATE] | ☐ Divorce ☐ Death |

Claimant's prior marriage(s):
| Former Spouse | Date Married | Date Ended | How Ended |
|--------------|--------------|------------|-----------|
| [NAME] | [DATE] | [DATE] | ☐ Divorce ☐ Death |

4.4 Post-Death Status

Have you remarried since the deceased's death?
☐ No
☐ Yes - Date of remarriage: [DATE]

PART 5: CHILD DEPENDENCY INFORMATION

5.1 Child Information

Child's Full Name: [NAME]

Date of Birth: [DATE]

Age at Time of Deceased's Death: [AGE]

Current Age: [AGE]

5.2 Parent-Child Relationship

Relationship Type:
☐ Biological child
☐ Legally adopted child (Date of adoption: [DATE])
☐ Stepchild
☐ Child for whom deceased was legal guardian
☐ Posthumous child (born after deceased's death)

Birth Certificate Number: [NUMBER]

Adoption Decree Number (if applicable): [NUMBER]

5.3 Legal Custody

Who had legal custody of the child at time of death?
☐ Deceased worker
☐ Other parent: [NAME]
☐ Both parents jointly
☐ Guardian: [NAME]
☐ Other: [EXPLAIN]

5.4 Living Arrangement

Was the child living with the deceased at time of death?
☐ Yes - Full time
☐ Yes - Part time (explain): [VISITATION SCHEDULE]
☐ No - Explain: [REASON]

5.5 Adult Child Status (if over 18)

If child is over 18, indicate basis for dependency:

☐ Enrolled full-time in school
School Name: [NAME]
Expected Graduation: [DATE]

☐ Physically incapacitated
Nature of incapacity: [DESCRIBE]
Date incapacity began: [DATE]

☐ Mentally incapacitated
Nature of incapacity: [DESCRIBE]
Date incapacity began: [DATE]

☐ Other: [EXPLAIN]

PART 6: OTHER DEPENDENT INFORMATION

6.1 Relationship

Relationship to Deceased: [RELATIONSHIP]

Was the claimant a member of the deceased's household?
☐ Yes ☐ No

If No, explain the living arrangement:
[EXPLAIN]

6.2 Proof of Dependency

To establish dependency-in-fact, describe:

Nature of Financial Support Provided by Deceased:
[DESCRIBE - e.g., paid rent, utilities, food, medical care, etc.]

____________________________________________________________________________

____________________________________________________________________________

Amount of Support Provided:
$[AMOUNT] per [WEEK/MONTH/YEAR]

What percentage of claimant's support came from deceased?
[___]%

How long had deceased provided this support?
[DURATION]

Would claimant have been destitute without deceased's support?
☐ Yes ☐ No

PART 7: FINANCIAL DEPENDENCY EVIDENCE

7.1 Deceased's Financial Contributions

Describe all financial contributions deceased made to claimant:

7.2 Claimant's Other Income/Support

Claimant's income from sources other than deceased:

7.3 Dependency Calculation

Total Annual Support from Deceased: $[AMOUNT]

Total Annual Income from Other Sources: $[AMOUNT]

Percentage of Support from Deceased: [___]%

PART 8: COMPETING CLAIMS

8.1 Other Potential Dependents

Are there other persons claiming dependent status?
☐ No
☐ Yes - List below:

8.2 Disputes

Is there any dispute regarding dependent status?
☐ No
☐ Yes - Explain:
[DESCRIBE DISPUTE]

____________________________________________________________________________

PART 9: BENEFITS REQUESTED

9.1 Benefits Claimed

This claimant requests:

☐ Weekly death benefits at rate of: $[AMOUNT]/week (or as determined by law)

☐ Share of death benefits proportionate to dependency

☐ Burial/Funeral expense reimbursement: $[AMOUNT]

☐ Medical expenses incurred before death: $[AMOUNT]

☐ Other: [SPECIFY]

9.2 Payment Instructions

Make payments to:

☐ Claimant directly
☐ Claimant's guardian/conservator: [NAME]
☐ Trust for minor child: [TRUST NAME]
☐ Claimant's attorney (in trust): [ATTORNEY NAME]

Send payments to:
[NAME]
[ADDRESS]
[CITY], [STATE] [ZIP CODE]

PART 10: SUPPORTING DOCUMENTS

10.1 Required Documentation

Attach the following (check all attached):

For All Claimants:
☐ Claimant's identification (driver's license, passport, etc.)
☐ Social Security card or statement
☐ Proof of relationship to deceased

For Spouse:
☐ Marriage certificate (certified copy)
☐ Domestic partnership registration (if applicable)
☐ Divorce decree from prior marriages
☐ Joint tax returns
☐ Joint bank account statements
☐ Proof of shared residence

For Children:
☐ Birth certificate
☐ Adoption decree (if applicable)
☐ School enrollment verification (if over 18)
☐ Medical documentation of incapacity (if applicable)
☐ Custody order (if applicable)

For Other Dependents:
☐ Tax returns showing dependent status
☐ Bank records showing regular support payments
☐ Bills paid by deceased on behalf of claimant
☐ Affidavits from persons with knowledge of dependency

PART 11: DECLARATION

11.1 Claimant's Declaration

I, [CLAIMANT NAME], declare under penalty of perjury under the laws of the State of [STATE] that:

☐ The information provided in this claim is true, correct, and complete to the best of my knowledge.

☐ I was dependent upon [DECEASED WORKER NAME] at the time of [his/her] death as stated herein.

☐ I have disclosed all sources of income and support.

☐ I have disclosed all other persons who may be entitled to death benefits as dependents.

☐ I understand that making false statements to obtain workers' compensation benefits is a crime.

☐ I agree to notify the claims administrator of any change in my dependency status.

☐ I authorize investigation of my dependency status, including verification of financial information.

Claimant Signature: _________________________________

Printed Name: [NAME]

Date: [DATE]

11.2 Guardian/Representative Declaration (if applicable)

I, [NAME], declare that:

☐ I am the legal guardian/representative of [CLAIMANT NAME].

☐ I am authorized to file this claim on behalf of the claimant.

☐ The information provided is true and correct to the best of my knowledge.

Representative Signature: _________________________________

Printed Name: [NAME]

Relationship: [RELATIONSHIP]

Date: [DATE]

PART 12: CORROBORATING DECLARATION

Declaration of [WITNESS NAME]

I, [WITNESS NAME], declare under penalty of perjury:

☐ I have personal knowledge of the relationship between [CLAIMANT NAME] and [DECEASED NAME].

☐ I know that [DECEASED NAME] regularly provided financial support to [CLAIMANT NAME] in the form of:
[DESCRIBE SUPPORT]

____________________________________________________________________________

☐ I estimate this support was approximately $[AMOUNT] per [PERIOD].

☐ Based on my knowledge, [CLAIMANT NAME] was [wholly/partially] dependent on [DECEASED NAME] for [his/her] support.

Witness Signature: _________________________________

Printed Name: [NAME]

Address: [ADDRESS]

Phone: [PHONE]

Relationship to Parties: [RELATIONSHIP]

Date: [DATE]

PART 13: FILING INFORMATION

13.1 File With

Workers' Compensation Board/Commission:
[AGENCY NAME]
[ADDRESS]
Phone: [PHONE]

Insurance Carrier:
[CARRIER NAME]
[ADDRESS]
Phone: [PHONE]

13.2 Deadlines

Filing Deadline for Dependent Claim: [DATE]

[END OF DOCUMENT]