Free LIBC-386 REV 2-05.indd - Pennsylvania


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Date: July 25, 2005
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State: Pennsylvania
Category: Workers Compensation
Word Count: 676 Words, 8,586 Characters
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URL

http://www.dli.state.pa.us/landi/lib/landi/bwclibc-386.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 TTY 800-362-4228

FATAL CLAIM PETITION FOR COMPENSATION BY DEPENDENTS FOR DEATH RESULTING FROM OCCUPATIONAL DISEASE

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

/
DD YYYY

-

/

PA BWC Claim Number: Employer

(Not to be used where death results from silicosis, anthraco-silicosis and asbestosis.

(IF KNOWN)

Deceased Employee
First Name _______________________________ Last Name _________________________________________

Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County _________________________________ Telephone __________ __________-_______

Date of Birth ______/______/__________ MM DD YYYY

Date of Death ______/______/__________ MM DD YYYY

Dependent
First Name _______________________________ Street 1 Last Name _________________________________________

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 ______________________________

The petitioner respectfully alleges that: 1. Dependents of the deceased employee are as follows:
NAME
_ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________

RESIDENCE
_____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________ _____________________________________________________

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

RELATIONSHIP
________/________/____________ ________/________/____________ ________/________/____________ ________/________/____________ ________/________/____________

2. The petitioner is is not a widow/widower of deceased. (a) If petitioner is a widow or widower, state where ceremony was performed and give date of marriage. ______________________________________________________________________________________ (b) Was marriage a common law marriage? Yes No
______/______/___________
MM DD YYYY

NOTICE: Petition should be clearly completed (preferably typed) and original mailed to the Bureau at the address in the upper left corner. (OVER)
LIBC-386 REV 2-05 (Page 1)

386 0205

3. By whom was the deceased employed at the time of the disability? (Give name, address, place of business
and business address.) (If the deceased employee was not directly employed by the defendant, state by whom he/she was employed, the work on which he/she was engaged, place of work, and the relation between the direct employer and the defendant.)

__________________________________________________________________________________________________ __________________________________________________________________________________________________ 4. The death was the result of the following occupational disease, compensable under paragraph ______________________ of Section 108 of the Occupational Disease Act. 5. The deceased employee first became disabled from earning full wages in the employment in which he was employed on ____/____/______ while in the employ of _____________________________________________________________.
MM DD YYYY

6. The deceased employee was last exposed in a hazardous occupation to the occupational disease of which he/she died while in the employ of the defendant on ____/____/______ as ____________________________________________________. 7. After the date of disability set forth in paragraph 5, the deceased employee was employed as ________________________ __________________________________________________________________________________________________ 8. The deceased employee received aid from the following doctors and/or hospitals: (Give names and addresses. If none, so state.) __________________________________________________________________________________________________ 9. Expenses of the last illness and burial amounted to $____________.______ Amount paid by the employer $____________.______ 10. On the date that the disability began, the average weekly wage of the decedent was $____________.______ 11. Compensation was was not paid to the decedent after the date of disability as follows:
MM DD YYYY

__________________________________________________________________________________________________ __________________________________________________________________________________________________ 12. The deceased employee's disability did did not develop to the point of disablement after exposure of five or more years. If it did, attach a list of all employers for ten years preceding date of disability, with dates each employment began and ended. 13. The claimant set forth the following additional facts which are believed to be important:_____________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ WHEREFORE, the claimant asks that the Workers' Compensation Judge make an award that the defendant shall pay such compensation as may be due under the Pennsylvania Occupational Disease Act. DATE OF THIS NOTICE: ____/____/_______
MM DD YYYY

PLEASE ENTER MY APPEARANCE FOR PETITIONER:

Attorney
Name

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

___________________________________________________________________________ Firm Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code _______________________________________ Telephone (______) _______-________________________ _________ _____________-_______ PA Attorney ID Number ________________________________

Petitioner
First Name _______________________________ Signature Last Name ______________________________________________

________________________________________________________________________________

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. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program
LIBC-386 REV 2-05 (Page 2)