Form 20 - Proof Of Loss (Death Claim)
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1THIS SPACE FOR COURT USE ONLY
COURT OF EXISTING CLAIMS
FORM 20
1915 NORTH STILES
Send original to
Court of Existing Claims and 1 copy to
OKLAHOMA CITY, OKLAHOMA 73105-4918
All Other Parties of Record
IN THE MATTER OF THE DEATH OF
(PLEASE TYPE OR PRINT)
Full Name of Deceased Employee
Full Name of Person Filing Proof of Loss
PROOF OF LOSS (DEATH CLAIM)
(Lump Sum Benefits)
Name of Employer
.
WCC FILE NO
Employer’s Insurance Carrier, Permit # for Court Approved Individual Self-Insured or Own Risk
Deceased Employee’s Social Security Number (LAST 4 DIGITS ONLY)
Group, Uninsured
XXX-XX-_____________________
STATE OF OKLAHOMA
)
)
SS.
COUNTY OF __________________________)
(PLEASE TYPE OR PRINT)
__________________________________________________, (name of person filing proof of loss) of lawful age, being first duly sworn on oath, alleges and
states:
The affiant is the ______________________________________________, (relation to deceased employee) of the deceased employee.
The above named deceased sustained a compensable accidental injury on or about _____________________________, ___________ while in the employ
of the employer, from and as a result of which the deceased died on ______________________________________, ____________.
At the time of death, the deceased was lawfully married to _______________________________________________________________ (name of spouse)
whose address is ____________________________________________________________________ and left surviving the following named children and
dependents:
CHILDREN (List additional children on the back of this form.)
FULL NAME
DATE OF BIRTH
ADDRESS
1. _______________________________________________________
_________________
_____________________________________________
2. _______________________________________________________
_________________
_____________________________________________
3. _______________________________________________________
_________________
_____________________________________________
4. _______________________________________________________
_________________
_____________________________________________
DEPENDENTS (Parents, brothers, sisters, grandparents and grandchildren, as defined by and if ACTUALLY DEPENDENT under the workers’ compensation
laws of Oklahoma. List additional actual dependents on the back of this form. Clearly identify them as “Dependents.”)
FULL NAME
DATE OF BIRTH
ADDRESS
1. _______________________________________________________
_________________
_____________________________________________
2. _______________________________________________________
_________________
_____________________________________________
3. _______________________________________________________
_________________
_____________________________________________
4. _______________________________________________________
_________________
_____________________________________________
I affirm I have read this Proof of Loss and declare under penalty of perjury that all statements are true and accurate to the best of my knowledge and belief.
I certify that on ___________________________________, ________ I mailed a copy of necessary marriage, birth and death certificates to the opposing
party/counsel as noted below. NOTE: A certified copy of each of these documents, and other documents necessary to establish actual dependency
as defined by law, must be offered at the time of trial or settlement.
Any person who commits workers’ compensation
______________________________________________________________________
fraud, upon conviction, shall be guilty of a felony.
Signature of Person Completing this Proof of Loss
DATE
I HEREBY CERTIFY THAT A COPY HAS BEEN SENT TO:
Opposing Party
Name of claimant’s attorney, if represented
OBA #
Address (Number and Street)
Address of Attorney (include City, State and Zip Code)
City
State
Zip Code
Telephone #
Signature of Claimant’s Attorney
DATE
C. 02/01/2014
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