Free LIBC-384 REV 4-04 - Pennsylvania


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State: Pennsylvania
Category: Workers Compensation
Word Count: 577 Words, 8,316 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dli.state.pa.us/landi/lib/landi/bwc/LIBC-384.pdf

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COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383

FATAL CLAIM PETITION FOR COMPENSATION BY DEPENDENTS FOR DEATH COVERED BY THE PENNSYLVANIA OCCUPATIONAL DISEASE ACT

Deceased's Social Security Number: Date of Injury:
MM

/
DD YYYY

-

/

PA BWC Claim Number:
(IF KNOWN)

Deceased Employee
First Name _______________________________ Last Name _________________________________________

Employer
Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code Last Name _________________________________________ __________________________________________ County _________________________________ Telephone (______) _______-_______________ __________ __________-_______

Date of Birth ______/______/________ MM DD YYYY

Date of Death ______/______/________ MM DD YYYY

Dependent
First Name _______________________________ Street 1

FEIN _________________________

___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County __________ Telephone __________-_______

VS.

Insurer or Third Party Administrator (if self-insured)
Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-_______________ County ______________________________ Claim Number ______________________________ __________ Bureau Code __________-_______

___________________________________________ (______) _______-_______________

Injury
Description of Injury and Cause of Death ___________________________________________________________________________

___________________________________________________________________________

____________________________

___________________________________________________________________________

___________________________________________________________________________

FEIN ___________________________

___________________________________________________________________________

___________________________________________________________________________

1. Death was a result of



Silicosis



Anthraco-Silicosis



Asbestosis

2. The deceased employee has been employed in a hazardous occupation in the Commonwealth of Pennsylvania having a G Silica hazard G Asbestos hazard for at least two years in the aggregate during the ten years preceding disability as follows:
NAME OF EMPLOYER IN PENNSYLVANIA ADDRESS DATES OF EMPLOYMENT FROM TO
(MM/DD/YYYY) _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ ________/________/__________ ________/________/__________ ________/________/__________ ________/________/__________ ________/________/__________ (MM/DD/YYYY) ________/________/____________ ________/________/____________ ________/________/____________ ________/________/____________ ________/________/____________

3. The deceased employee was last engaged in a hazardous occupation having a G Silica hazard G Asbestos hazard in the employ of the defendant on _____/_____/_________.
MM DD YYYY

4. The deceased employee became totally disabled on _____/_____/_________.
MM DD YYYY

LIBC-384 REV 4-04 (Page 1)

(OVER)

5. The deceased employee received aid from the following doctors and/or hospitals: (Give names and addresses. If none, so state.) __________________________________________________________________________________________________ __________________________________________________________________________________________________ 6. Expenses of the last illness and burial amounted to $__________._____ Amount paid by the employer $__________._____ 7. The average weekly wage of the deceased employee in the employ of the defendant employer was $________._____. 8. Was compensation paid to the deceased employee between the time total disability began and the date of his/her death? G Yes G No If Yes, payments began on ____/____/______
MM DD YYYY

9. Dependents of the deceased employee are as follows:
NAME
_________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________

RESIDENT
_____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________

DATE OF BIRTH
(MM/DD/YYYY) ________/________/__________ ________/________/__________ ________/________/__________ ________/________/__________ ________/________/__________

RELATIONSHIP
_____________________________ _____________________________ _____________________________ _____________________________ _____________________________

10. The petitioner G is G is not a.

a widow/widower of the deceased.

If petitioner is a widow or widower, state where ceremony was performed and give date of marriage. _______________________________________________________________________ _____/_____/______
MM DD YYYY

b.

Was marriage a common law marriage?

G Yes G No

11. The claimant has provided the following additional information: ________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ WHEREFORE, the aforementioned claimant asks that the Bureau make an award that the defendant shall pay such compensation as due under the Pennsylvania Occupational Disease Act. DATE OF THIS NOTICE: ____/____/_______
MM DD YYYY

PLEASE ENTER MY APPEARANCE FOR PETITIONER:

Attorney
Name ___________________________________________________________________________ Firm Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2

I hereby certify that a copy of this Petition has been served on the opposing party. __________________________________________________
SIGNATURE OF PETITIONER OR REPRESENTATIVE

Petitioner
First Name _______________________________ Signature Last Name ______________________________________________

___________________________________________________________________________ City/Town State Zip Code __________________________________________ __________ __________-_______ Telephone PA Attorney ID Number (______) _______-________________________ ________________________________

________________________________________________________________________________

NOTICE: This petition should be clearly completed (preferably typed) and original mailed to the Bureau at the address in the upper left corner on the front. Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994.
LIBC-384 REV 4-04 (Page 2)

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