Free deathben.PDF - North Carolina

NORTH CAROLINA INDUSTRIAL COMMISSION

DOCKET NO.___________________________

CLAIM FOR BENEFITS UNDER THE LAW ENFORCEMENT OFFICERS', FIREMEN'S, RESCUE SQUAD WORKERS' AND CIVIL AIR PATROL MEMBERS' DEATH BENEFITS ACT, G. S. 143-166, ET SEQ. ___________________________________ (Print Name of Claimant) 1. 2. 3. 4. 5. ______________________, being first duly sworn, deposes and says: (County)

This claim is filed for benefits under the Law Enforcement Officers' Death Benefits Act by reason of the death of ________________________________________________________________________ The said employee was killed in the discharge of his/her official duties as a full-time law enforcement officer on the ________ day of _______________________________________, 200_____. The injury and death occurred in the following manner: ________________________________________ _____________________________________________________________________________________________ The name of the employer was ________________________________________________________________ (address)____________________________________________________________________________________ Workers' compensation benefits have been paid or are being paid by reason of this death and I. C. File Number _________________________ has been assigned to said workers' compensation claim. The name, address, and social security number of the surviving spouse are: (Name)__________________________________________________________ (SSN)_______________________ (Address)____________________________________________________________________________________ The names, dates of birth, addresses, and social security numbers of the minor children of this employee are (please list additional children on back of this form): (Name)___________________________________ (Relationship)_____________ (SSN)___________________ (Address)____________________________________________________________________________________ (Name)___________________________________ (Relationship)_____________ (SSN)___________________ (Address)____________________________________________________________________________________

6.

7. 8.

The surviving spouse was , was not residing with employee on the date of the injury or death. Date of marriage:__________________________ Place of marriage:_________________________________ There are no children or eligible surviving spouse. The eligible beneficiaries are listed below: (Name)__________________________________________________________ (SSN)_______________________ (Address)____________________________________________________________________________________ (Name)__________________________________________________________ (SSN)_______________________ (Address)____________________________________________________________________________________

9.

The surviving spouse resided with employee continuously for 6 months prior to death? Yes__ No__ ______________________________________________ (Signature of Claimant)

Subscribed and sworn to before me this the _____ day of _________________, 200____.

________________________________________ (Address)

______________________________________________________ Signature and Seal of Notary Public or Clerk of Court My Commission expires:______________________________ PLEASE SUBMIT TO: MS. LINDA LANGDON, DOCKET DIRECTOR 4336 MAIL SERVICE CENTER RALEIGH, NORTH CAROLINA 27699-4336