Form C-62 - Claim For Compensation In A Death Case

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State of New York - Workers' Compensation Board

CLAIM FOR COMPENSATION IN A DEATH CASE

This claim will be

more quickly if copies of necessary documents are submitted to the Board. Attach copies of the documents which you have in your

processed

possession. Otherwise obtain copies and bring them to the first hearing. DO NOT DELAY filing this claim form. Necessary documents are as follows: a.

medical report from doctor who treated the deceased.

b. Death certificate.

c. Proof of relationship such as birth certificate, marriage certificate, adoption papers, etc.

d. Itemized funeral bill.

(if known)

W.C.B. CASE NO.

CARRIER CASE NO.

CARRIER CODE NO.

DECEDENT'S SOC. SEC. NO. CLAIMANT'S SOC. SEC. NO.

DATE OF ACCIDENT

NAME

ADDRESS (Give No, Street,City, State and Zip Code)

Apt. No.

DECEASED

EMPLOYER

CARRIER

Apt. No.

CLAIMANT

I hereby make claim under the Workers' Compensation Law for compensation arising out of the death of the deceased named above as the

result of injury sustained in the employ of the above named employer, and, in support of this claim submit the following information:

1. a. Death occurred on ................................................................ day of ................................................................. , ........................................

at ..................................................................................................................................................... (Attach death certificate, if available).

b. How did accident or occupational disease happen? (Describe fully, stating whether the injured person fell, was struck, etc. and what

factors or events led up to or contributed to the accident.)

................................................................................................................................................................................................................

c. Place of Accident: .......................................................................................................................................................................................

d. Nature of injury and part(s) of body injured: ...............................................................................................................................................

Note: Attach a medical report, if available.

Name

Address

ATTENDING

PHYSICIAN

LAST PHYSICIAN

OR HOSPITAL

UNDERTAKER

PERSON WHO PAID

UNDERTAKER BILLS

6. Amount of Undertaker's Bills $__________________ Amount paid, if any $________________________ (Attach funeral bill, if available.)

7. Claimant's date of birth ____________________________ 8. Relationship to deceased _______________________________________