Free Fatality form.PDF - Arizona

BEFORE THE INDUSTRIAL COMMISSION OF ARIZONA
CLAIM FOR DEPENDENT' BENEFITS ­ FATALITY S
CHECK APPROPRIATE BOX: SPOUSE SPOUSE WITH DEPENDENT CHILDREN DEPENDENT CHILDREN (Must be filed by guardian) INFORMATION REGARDING DECEASED: 1. 2. 3. 4. Name of Deceased: Date of Birth: Date of Injury: (If different from date of death): Deceased' Address: s Soc. Sec. # *: Date of Death: PARENTS OTHER DEPENDENTS BURIAL EXPENSE ONLY

5.

Employer at time of death: Employer' address: s

6.

Briefly state cause of death:

7.

List name and address of health care providers that treated deceased in the last two years and state condition treated:

CLAIM FOR SPOUSAL BENEFITS: (Provide certified copy of marriage certificate.) 1. 2. Your Full Name: Your Address: Date of Birth:

3.

Date of Marriage to Deceased: Place of Marriage:

4.

Were You or Deceased Married Previously? decrees.

Yes

No If yes, state details and provide copies of divorce

(Rev. 5/00)

5.

Did you reside with deceased at time of death? divorce pending, annulment, abandonment.

Yes

No If living apart provide reason, such as divorced,

CLAIM FOR DEPENDENT CHILDREN: (Provide certified copies of birth certificates.) 1. List dependent children:
NAME DATE OF BIRTH RELATIONSHIP TO DECEASED ADDRESS AT TIME OF DEATH

2.

Which of these children are still in your care and custody?

3

Is a posthumous (unborn) child expected?

Yes

No If yes provide anticipated date of delivery:

OTHER DEPENDENTS: 1. 2. Name: Address:

3. 4.

Relationship to Deceased: Extent of Dependency: Full Partial Please give details:

DATE

SIGNATURE OF/OR ON BEHALF OF DEPENDENT TELEPHONE NUMBER

To be filed at either office of the Industrial Commission: Phoenix Office: Industrial Commission of Arizona 800 W. Washington Street Phoenix, Arizona 85007-2922 P. O. Box 19070 Phoenix, Arizona 85005-9070
The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commission' forms, prescribed under the Commission' Rules in existence prior to January 1, 1975, required disclosure of the s s social security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by the social security number. THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CONTACT SPECIAL SERVICES AT (602) 542-1829.

Tucson Office:

Industrial Commission of Arizona 2675 E. Broadway Tucson, Arizona 85716-5342