Commonwealth of Pennsylvania
Department of General Services
(11/05)
REPORT OF DEATH
PUBLIC SAFETY WORKER
TO BE COMPLETED BY POLITICAL SUBDIVISION OR COMMONWEALTH AGENCY
-
INSTRUCTIONS ON REVERSE
____________________________________________________________________________________________________
Name and Mailing Address of Political Subdivision or Commonwealth Agency in whose service death occurred
________________________________________________________________________________________________________
Name of Deceased (Last, First, Middle)
| Social Security # | Date of Injury | Date of Death
|
|
|
______________________________________________________|___________________|________________|____________________________
Deceased’s Last Mailing Address
________________________________________________________________________________________________________
Name of Deceased’s Superior Officer and Telephone Number (include Area Code)
________________________________________________________________________________________________________
At the time of
___ Yes
___ No
injury that resulted in death, was the Deceased in the Performance of Duties?
In the Capacity as a
Employment Status
___ Police Officer
___ Full Time
___ Correction Officer
___ Part Time
___ Firefighter
___ Volunteer
___ Ambulance/Rescue Squad
___ Other(Specify)_________________
___ Other(Specify)_____________________________
_______________________________________________________________________________________________________
Name, address and telephone number of Political Subdivision employee responsible for issuing payment to
the beneficiary(ies), if claim is determined to be eligible.
_______________________________________________________________________________________________________
CERTIFICATION
I certify that the information provided above and on any of the attachments is correct to the best of
my knowledge and belief.
I hereby request a determination of eligibility under Act 101 of 1976, as
amended.
Sworn and subscribed before me this ______ day
of _____________________ A.D., 20 ____
______________________________________________
(SEAL)
Signature - Authorized Official
Date
______________________________________________
____________________________________
Signature - Notary Public
Typed Name of Official
My Commission Expires ________________________
_____________________________________
Title
________________________________________________________________________________________________________
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