Death Benefits Report

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AWCB Case Number:
ALASKA DEPARTMENT OF LABOR &
WORKFORCE DEVELOPMENT
DEATH BENEFITS REPORT
Alaska Workers' Compensation Board
P.O. Box 115512, Juneau AK 99811-5512
Complete this form and attach to Compensation Report (Form 07-6104) when you begin, change, suspend or terminate death benefits payments.
1. Deceased Employee's Name (Last, First, Middle Initial)
2. Insurer Claim Number
3. Date of Injury
4. Date of Death
5. Social Security Number
6. Place of Death
7. Date of Birth
8. Employer
9. Insurer
10. Address
11. Address
City
State
Zip Code
Telephone
City
State
Zip Code
Telephone
12. WIDOW(ER) AND/OR CHILDREN:
a. Name (Last, First Middle Initial)
Date of Birth
Weekly Rate
Date Benefits Terminated
Address
City
State
Zip Code
b. Name (Last, First Middle Initial)
Date of Birth
Weekly Rate
Date Benefits Terminated
Address
City
State
Zip Code
c. Name (Last, First Middle Initial)
Date of Birth
Weekly Rate
Date Benefits Terminated
Address
City
State
Zip Code
d. Name (Last, First Middle Initial)
Date of Birth
Weekly Rate
Date Benefits Terminated
Address
City
State
Zip Code
e. Name (Last, First Middle Initial)
Date of Birth
Weekly Rate
Date Benefits Terminated
Address
City
State
Zip Code
13. DEPENDENT PARENTS, GRANDCHILDREN, BROTHER(S) AND/OR SISTER(S):
a. Name (Last, First Middle Initial)
Date of Birth
Weekly Rate
Date Benefits Terminated
Address
City
State
Zip Code
b. Name (Last, First Middle Initial)
Date of Birth
Weekly Rate
Date Benefits Terminated
Address
City
State
Zip Code
c. Name (Last, First Middle Initial)
Date of Birth
Weekly Rate
Date Benefits Terminated
Address
City
State
Zip Code
This is to certify that the original Death Benefits Report and the Compensation Report (Form 07-6104) have been mailed to all dependents at the above
address(es), and copies have been mailed to the Alaska Workers' Compensation Board.
14. Name and Title of Person Submitting Report (Print or Type)
16. Report Date
15. Signature
17. Address
City
State
Zip Code
Telephone
Form 07-6118 (Rev 04/2010)

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