Claim For Benefits Under The Law Enforcement Officers', Firemen'S, Rescue Squad Workers' And Civil Air Patrol Members' Death Benefits Act

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NORTH CAROLINA INDUSTRIAL COMMISSION
DOCKET NO.___________________________
CLAIM FOR BENEFITS UNDER THE LAW ENFORCEMENT OFFICERS’, FIREMEN’S, RESCUE SQUAD
WORKERS’ AND CIVIL AIR PATROL MEMBERS’ DEATH BENEFITS ACT, G. S. 143-166, ET SEQ.
___________________________________
______________________, being first duly sworn, deposes and says:
(Print Name of Claimant)
(County)
1.
This claim is filed for benefits under the Law Enforcement Officers’ Death Benefits Act by
reason of the death of ________________________________________________________________________
2.
The said employee was killed in the discharge of his/her official duties as a full-time law
enforcement officer on the ________ day of _______________________________________, 200_____.
3.
The injury and death occurred in the following manner: ________________________________________
_____________________________________________________________________________________________
4.
The name of the employer was ________________________________________________________________
(address)____________________________________________________________________________________
5.
Workers’ compensation benefits have been paid or are being paid by reason of this death
and I. C. File Number _________________________ has been assigned to said workers’ compensation
claim.
6.
The name, address, and social security number of the surviving spouse are:
(Name)__________________________________________________________ (SSN)_______________________
(Address)____________________________________________________________________________________
The names, dates of birth, addresses, and social security numbers of the minor children of this
employee are (please list additional children on back of this form):
(Name)___________________________________ (Relationship)_____________ (SSN)___________________
(Address)____________________________________________________________________________________
(Name)___________________________________ (Relationship)_____________ (SSN)___________________
(Address)____________________________________________________________________________________
7.
The surviving spouse was , was not
residing with employee on the date of the injury or death.
Date of marriage:__________________________ Place of marriage:_________________________________
8.
There are no children or eligible surviving spouse. The eligible beneficiaries are listed below:
(Name)__________________________________________________________ (SSN)_______________________
(Address)____________________________________________________________________________________
(Name)__________________________________________________________ (SSN)_______________________
(Address)____________________________________________________________________________________
9.
The surviving spouse resided with employee continuously for 6 months prior to death? Yes__ No__
______________________________________________
(Signature of Claimant)
Subscribed and sworn to before me this
the _____ day of _________________, 200____.
________________________________________
(Address)
______________________________________________________
Signature and Seal of Notary Public or Clerk of Court
My Commission expires:______________________________
PLEASE SUBMIT TO:
MS. LINDA LANGDON, DOCKET DIRECTOR
4336 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-4336

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