Alaska Department of Labor Alaska Workers Compensation Board P.O. Box 25512, Juneau, Alaska 99811-5512
AWCB Case Number
DEATH BENEFITS REPORT
Complete this form and attach to Compensation Report (Form 07-6104) when you begin, change, suspend or terminate death benefit payments.
1. Deceased Employees Name (Last, First, Middle Initial) 4. Death Date 6. Place of Death 8. Employer 10. Address City State Zip Telephone 9. Insurer 11. Address City State Zip Telephone 2. Insurer Claim Number 3. Date of Injury 5. Social Security Number 7. Date of Birth
12. WIDOW(ER) AND/OR CHILDREN:
a. Name (Last, First, Middle Initial) Address b. Name (Last, First, Middle Initial) Address c. Name (Last, First, Middle Initial) Address d. Name (Last, First, Middle Initial) Address e. Name (Last, First, Middle Initial) Address f. Name (Last, First, Middle Initial) Address Birthdate City Birthdate City Birthdate City Birthdate City Birthdate City Birthdate City Weekly Rate State Weekly Rate State Weekly Rate State Weekly Rate State Weekly Rate State Weekly Rate State Date Benefits Terminated Zip Code Date Benefits Terminated Zip Code Date Benefits Terminated Zip Code Date Benefits Terminated Zip Code Date Benefits Terminated Zip Code Date Benefits Terminated Zip Code
13. DEPENDENT PARENTS, GRANDCHILDREN, BROTHER(S) AND/OR SISTER(S):
a. Name (Last, First, Middle Initial) Address b. Name (Last, First, Middle Initial) Address c. Name (Last, First, Middle Initial) Address Relationship City Relationship City Relationship City Weekly Rate State Weekly Rate State Weekly Rate State Date Benefits Terminated Zip Code Date Benefits Terminated Zip Code Date Benefits Terminated 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) 17. Address Form 07-6118 (Rev. 1/94) 15. Signature City State Zip Report Date Telephone
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