Vital Information - Survivor'S Benefit Checklist Page 9
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12OTHER INSURANCE POLICIES
Company Name:
Type of Policy
Address:
Phone Number:
Policy Number
Location of Policy/Evidence of Coverage:
Company Name:
Type of Policy
Address:
Phone Number:
Policy Number:
Location of Policy/Evidence of Coverage:
RETIREMENT BENEFITS
Employer or Union's Name:
Type of Plan:
Phone Number:
Account Number:
OTHER RETIREMENT BENEFITS
Firm Name:
Type of Plan:
Phone Number:
Account Number:
Firm Name:
Type of Plan:
Phone Number:
Account Number:
VETERANS BENEFITS
Are you entitled to Veterans benefits?
Yes
No
SOCIAL SECURITY BENEFITS
Are you entitled to Social Security benefits?
Yes
No
BANK INFORMATION
Company Name:
Checking Acct. Number:
Savings Acct. Number:
Other Acct. Number:
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Form Ee-2 - Survivor's Claim For Benefits Under The Energy Employees Occupational Illness Compensation Program Act - United States Department Of Labor, Office Of Workers' Compensation Programs
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Parent category: Legal