Claim For Funeral Benefits Only
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2_____________________________
_______________ __
______________________________
_________________________________
_____________________________________________
WORKERS' COMPENSATION COMMISSION
CLAIM FOR FUNERAL BENEFITS ONLY
Instructions: This form may not be used if there are any dependents. This form must be completed in its entirety
and signed by the filing party. All provisions of address require a complete mailing address.
A Certification of Funeral Expenses (WCC Form C-18) must be attached.
1. Name of Deceased:
Address:
City:
State:________
ZIP Code:
2. Deceased's Social Security Number
3. Deceased's Date of Birth
)
(if known)
(mm/dd/yyyy
4. Name of Filing Party:
___________________________________________________________
Address:
_____________________________
State:________
ZIP Code:
_________________
City:
____________________________
Telephone Number:
5. Filing Party's Relationship to Deceased (spouse, child, parent, other):
__________________________________
6. I make this claim because:
___
I paid for funeral services and have not been reimbursed;
___
I provided funeral services and have
not been compensated;
___
Other:
_____________________________________________________
_____________________
7. Date of Injury/occupational disease disablement
(mm/dd/yyyy):_
8. Location Where Accident/Injury Occurred:
Address:
___________________________________________________________
_ ___________
City:
_________________________________
State
__________
ZIP Code:
9. Describe how the
___
accidental injury or
___
occupational disease occurred:
________________________________________________________________________________________________
_________________________________________________________________________________________
_______________________
10. Date of Death (mm/dd/yyyy):
11. Cause of Death:
________________________
________________________________________________________________________________________________
___________________________________________________________________
12. Deceased's Employer: Name:
Address:
_____________________________________________________________________
City:
________________________
State:
ZIP Code:
_________________
___________________
:____
_
_
Telephone Number:
Pursuant to Labor and Employment Article §9-689(c), I hereby make claim for the reimbursement of costs arising
from the funeral of the above named deceased employee.
I certify that, to the best of my knowledge, information and belief, the deceased employee has no dependents and
the information contained herein is accurate.
________________________________
____________________
Signature of Person Filing this Claim
Date
Click here to reset this form
10 East Baltimore Street w Baltimore, Maryland 21202-1641
410-864-5100 w Email: info@wcc.state.md.us w Web:
MD WCC C19 (07/01/08)
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