Claim Form For Death Benefits Public Safety Worker -Commonwealth Of Pennsylvania Department Of General Services
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1
2Commonwealth of Pennsylvania
Department of General Services
(11/05)
CLAIM FOR DEATH BENEFITS
PUBLIC SAFETY WORKER
TO BE COMPLETED BY CLAIMANT, POLITICAL SUBDIVISION OR COMMONWEALTH AGENCY - INSTRUCTIONS ON REVERSE
PART I - DECEASED PUBLIC SAFETY WORKER
_____________________________________________________________________________
Name of Deceased (Last, First, Middle)
| Social Security # | Date of Injury | Date of Death
|
|
|
_____________________________________________________|___________________|________________|_________________________
Name of Political Subdivision or Commonwealth Agency in whose service death occurred
____________________________________________________________________________________________________
Marital status at time of death
___ Married
___ Separated
___ Divorced
___ Single
____________________________________________________________________________________________________
If married or separated, was deceased married previously?
___ Yes
___ No
___ Unknown
____________________________________________________________________________________________________
PART II - SURVIVORS (INDICATE APPROPRIATE CATEGORY
___ SPOUSE
___ CHILD/CHILDREN
___ PARENT(S))
____________________________________________________________________________________________________
Name(s) (Last, First, Middle)
Address
Social Security #
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If child(ren) is the legal survivor(s), provide birthdate(s)________________________________________
Has a legal guardian been appointed for the child(ren)?
___ yes
___ no
If yes, Provide name and mailing address of guardian for each child.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
PART III - CERTIFICATION (MUST BE COMPLETED BY CLAIMANT OR LEGAL REPRESENTATIVE)
I hereby make claim for compensation for myself as, or in behalf of, the survivor(s) listed above,
under Act 101 of 1976, as amended, as a result of the death of the above named Public Safety Worker,
who was killed in the performance of duties.
Every statement and information set forth above and
attached is true to the best of my knowledge and belief.
Sworn and subscribed before me this ______ day
of _____________________ A.D., 20 ____
___________________________________
____________
(SEAL)
Signature - Claimant or Legal Rep
Date
______________________________________________
____________________________________
Signature - Notary Public
Typed/Printed Name
My Commission Expires ________________________
Telephone #
(
) ______________________________
____________________________________________________________________________________________________
PART IV - TO BE COMPLETED BY DEPARTMENT OF GENERAL SERVICES - BUREAU OF RISK AND INSURANCE MANAGEMENT
Based on this form and its attachments, it is our opinion that payment(s) in the total amount of
$______________
is justified under the conditions set forth under Act 101 of 1976, as amended.
_____________________________________
___________
Signature - Authorized Employee
Date
___________________________________________________
Title
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