Report Of Death Public Safety Worker Form - Commonwealth Of Pennsylvania Department Of General Services Page 2

Download a blank fillable Report Of Death Public Safety Worker Form - Commonwealth Of Pennsylvania Department Of General Services 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 Report Of Death Public Safety Worker Form - Commonwealth Of Pennsylvania Department Of General Services 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.

ADVERTISEMENT

Commonwealth of Pennsylvania
Department of General Services
(11/05)
REPORT OF DEATH
INSTRUCTIONS
A Political Subdivision or Commonwealth Agency is responsible for completion of all items.
The form must be signed by an authorized official and must be notarized.
Obtain the following documents:
1. Copy of Workers’ Compensation form filed on behalf of the Public Safety Worker.
2. Notarized statement from the supervisor or officer in charge describing in detail
the
duties being performed by the Public Safety Worker at the time
and the circumstances under which death occurred.
3. Certified copy of the Autopsy report.
4. Volunteers - Certified copy of the Fire Department/Ambulance Squad Letters of
incorporation or Charter.
5. Volunteers - A notarized statement form the Fire Chief/Commander providing a
complete description of the deceased’s membership information.
6. If the cause of death was medical, submit a notarized statement from a medical
expert that the death occurred as a result of the performance of duties and a detailed
analysis of the reason for his opinion.
Also, submit copies of any relevant
hospital/medical records.
7. Any other information that may assist in determining eligibility.
Submit Report of Death with required documents to:
Department of General Services
Bureau of Risk and Insurance Management
P.O. Box 1365
Harrisburg, PA 17105
Applies to Political Subdivision Only
Receive check from DGS and immediately process and deliver check(s) to beneficiary(ies).
Obtain copy of canceled check(s) and forward to DGS as soon as possible.

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Gs-1078 - Attestation Regarding Personnel Used In Contract Performance - Department Of General Services Form Gs-1078 - Attestation Regarding Personnel Used In Contract Performance - Department Of General Services Legal
Form Ap-2 - Pennsylvania Department Of Treasury Form Ap-2 - Pennsylvania Department Of Treasury Legal
Report Of Contractor Services Report Of Contractor Services Business
Claim Form For Death Benefits Public Safety Worker -commonwealth Of Pennsylvania Department Of General Services Claim Form For Death Benefits Public Safety Worker -commonwealth Of Pennsylvania Department Of General Services Legal
New Applicant For Eligibility Form - State Of California Department Of General Services New Applicant For Eligibility Form - State Of California Department Of General Services Legal
Statement Of Change Of Registered Office By Agent Form - Corporation Bureau Pennsylvania Department Of State Statement Of Change Of Registered Office By Agent Form - Corporation Bureau Pennsylvania Department Of State Legal
Clean And Green Application Form - Adamss County, Pennsylvania Department Of Agriculture Clean And Green Application Form - Adamss County, Pennsylvania Department Of Agriculture Legal
Instructions For Form Pa-41 - Pennsylvania Department Of Revenue - 1998 Instructions For Form Pa-41 - Pennsylvania Department Of Revenue - 1998 Financial
Request, Replace, Or Deactivate Nys Fuel Credit Card Request Form - New York Office Of General Services Request, Replace, Or Deactivate Nys Fuel Credit Card Request Form - New York Office Of General Services Legal
Faqs About Reporting Delinquent Participant Contributions On The Form 5500 - U.s. Department Of Labor Faqs About Reporting Delinquent Participant Contributions On The Form 5500 - U.s. Department Of Labor Financial

Related Categories

Parent category: Legal
Download
Go
Page of 2