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)
Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program