Form C-62 - Claim For Compensation In A Death Case Page 2

Download a blank fillable Form C-62 - Claim For Compensation In A Death Case in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form C-62 - Claim For Compensation In A Death Case with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

11.

IF YOU ARE THE SPOUSE OR CHILD OF THE DECEASED ENTER THE FOLLOWING INFORMATION AS APPLICABLE:

a. You were married to the deceased on _______________________day of ____________________________,________________

at _________________________________ by ___________________________________ (Attach marriage certificate, if available).

(Place)

Person Performing Ceremony

b. Number of children under 18 years of age at the time of the death of the deceased. _________________

c. Number of children at least 18 years of age but under 23, enrolled and attending as full time students in any accredited educational

institution at the time of the death of the deceased._______________

12.

IF YOU ARE THE SPOUSE OF THE DECEASED, indicate your share of survivor's insurance benefits, if any, being received under the

Social Security Act. $_____________ (If available, attach copy of Social Security Award certificate showing your share of survivor's

insurance benefits or copy of check showing the amount of the award.)

13.

IF YOU ARE NEITHER THE SPOUSE OF THE DECEASED OR CHILD OF THE DECEASED UNDER 18 YEARS OF AGE OR UNDER

23 YEARS ENROLLED AND ATTENDING AS A FULL TIME STUDENT IN ANY ACCREDITED EDUCATIONAL INSTITUTION, ENTER

THE FOLLOWING INFORMATION:

a. Were you wholly or partially dependent on the deceased for your support? _________________

b. If partially dependent, to what degree?

_____________________

c. I own property as follows:

(1) Real estate, assessed value $____________________________, from which I receive an income of $_______________

annually and on which there is an indebtedness of $ ____________________.

(2) What other sources of income do you have? (Name each source and give amounts derived from each source named.)

SOURCE

AMOUNT

14.

IF YOU ARE A CHILD OR DEPENDENT GRANDCHILD, DEPENDENT BROTHER OR DEPENDENT SISTER, AT LEAST 18 YEARS

OF AGE BUT UNDER 23 AND ENROLLED AND ATTENDING AS A FULL TIME STUDENT IN ANY ACCREDITED EDUCATIONAL

INSTITUTION, ENTER THE FOLLOWING INFORMATION AND ATTACH CERTIFICATION OF ATTENDANCE, IF AVAILABLE FROM

SUCH INSTITUTION.

Name of Student

Name & Address of Educational Institution

Date Attendance Began

ANY PERSON WHO KNOWINGLY AND W ITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES W ITH KNOWLEDGE OR BELIEF THAT

IT W ILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY

MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.

Dated_____________________ Signed by ________________________________________________________________________ or

(Claimant's Signature)

Telephone No.

Signed by __________________________________________________________________________________________________

(A person on behalf of Claimant)

(Relationship)

Telephone No.

TO THE CLAIMANT

A. Under the Workers' Compensation Law, a claim for compensation in a death case may be filed by:

1. Spouse of the deceased;

2. Children of the deceased who are under age 18 at the time of death;

3. Children of any age who were totally blind or physically disabled at the time of accident and whose disablement is total and permanent;

4. Grandchildren and brothers and sisters of the deceased who were under the age of 18 at the time of death and wholly or partially dependent

upon the deceased for support at the time of accident;

5. Parents and grandparents of the deceased who were wholly or partially dependent upon the deceased for support at the time of accident;

6. Children of the deceased, dependent grandchildren, dependent brothers and dependent sisters of the deceased under the age of 23 who are

enrolled and attending as full time students in any

educational institution, where death occurs on or after January 1, 1978.

accredited

B. The spouse and the children may file a single claim. Each dependent grandchild, brother, sister, parent or grandparent must file a separate claim.

Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers Law Article 6-A) and the Federal Privacy Act of 1974 (5 U.S.C. Sec. 552a).

The Workers' Compensation Board's ("Board") authority to request personal information from claimants is derived from Sections 20 and 142 of the Workers'

Compensation Law. This information is collected to assist the Board in processing claims in an efficient manner and to help it maintain accurate claim records.

The Board is strongly committed to protecting the confidentiality of all personal information that it collects. Such information will be disclosed within the agency

only to Board personnel and agents in furtherance of their official duties. Personal information will be disclosed outside the agency only in accordance with applicable state

and federal law.

The Board's Director of Operations, located at 100 Broadway, Menands, New York 12241 (518-474-6674), is primarily responsible for the maintenance of agency

records containing personal claimant information.

Failure to provide the information requested on this form will not result in the denial of your claim, but may delay the processing of your claim. The voluntary

release of your social security number enables the Board to ensure that information is associated with, and quick action is taken on, your claim.

NYS Workers' Compensation Board

Centralized Mailing

PO Box 5205

Binghamton, NY 13902-5202

Customer Service Toll-Free Number: 877-632-4996

C-62 (1-11) Reverse

Statewide Fax Line: 877-533-0337