Spouse-Dependent(s) Report Of Death {SFN 10012}

C8 SPOUSE/DEPENDENT(S) REPORT OF DEATH CLAIMS DIVISION SFN 10012 (0 9 /201 5 ) 1600 E Century A ve , S te 1 PO Box 5585 Bismarck ND 58506 - 5585 Telephone 800 - 777 - 5033 Toll Free Fax 888 - 786 - 8695 TTY ( hearing impaired ) 800 - 366 - 6888 Fraud and Safety Hotline 800 - 243 - 3331 www.workforcesafety.com P l e ase print or type using black or blue ink and return to WSI. surviving spouse and/or dependent(s) or guardian of the dependent child(ren). Application for death benefits must be made by the beneficiary or administrator of the decedent within two years of the da te of death. SECTION 1 information Claim number (F irst name) ( L ast name) Social S ecurity number* Date of birth Sex Female Male Marital status of deceased worker Single Married M ailing address ( S treet address, PO Box number) City State ZIP c ode SECTION 2 Survivin g spouse/dependent(s) or guardian applying for benefits Spouse, dependent or guardian ( F irst name) (L ast name) Relationship to deceased Date of birth Social S ecurity number* T elephone number M ailing address ( S treet address, PO Box number) City State ZIP c ode List dependents under age 18, or under age 23 if attending school, or incapable of self - support. Use back of form if needed. Name Date of birth Social Security number* Relationship to deceased Please submit a photocopy of the following documents if available Death Certificate Autopsy Report if performed Marriage Certificate if applicable SECTION 3 Accident information Date of accident Time of accident AM PM D ate of death Where did accident happen? (City) (County) (State) How did accident happen? Treating doctor(s) name Clinic/hospita l name Clinic/hospital mailing address City State ZIP c ode Form continued on next page. Please submit all pages to WSI. American LegalNet, Inc. www.FormsWorkFlow.com C8 SPOUSE DEPENDENT(S) REPORT OF DEATH Page 2 of 2 SFN 10012 (09/2015) Claim number (First name) (Last name) SECTION 4 Telephone number Ma iling address (Street address, PO Box number) City State ZIP code SECTION 5 Release of information/fraud warning/signature Release of information I understand and agree that North Dakota law determines all my rights and obligations to and from WSI. I authorize any medica l compensation relating to work injuries, any law enforcement or military agency, any government benefit agency including the Social Security Administration, and any educational agency or institution to release to WSI, its agents and attorneys, any and all i nformation or records, including all prior records as well as those pertaining to mental health, alcohol, or drug abuse, and HIV/AIDS/AIDS - related illness. I authorize healthcare providers to respond to WSI regarding my injury, including request for conclu sions and opinions not otherwise contained within existing medical records. In addition, 21 Sec. 1232g. This authorization contin ues while I have any claim open or pending before WSI. WSI is exempt from HIPAA regulations. I authorize WSI to release any information or records about my claim to third parties or their insurers for the purpose of re solving claims against third parties. I authorize the release of any medical information related to my claim to my employer. Fraud warning Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the receipt of benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fine s, or both. These criminal penalties are applicable to all persons dealing with WSI, including injured workers, employers, medical provid ers, and attorneys. Signature By signing this form, I acknowledge that I have read and understand the r elease of i nformation an d fraud w arning. I understand that falsifying this claim or making a false statement regarding this claim may be a felony, punishable by substantial fines and i mprisonment. I authorize the release of information and agree that statements in this form are t rue and accurate. Date signed SECTION 6 Additional information or comments * In compliance with the Federal Privacy Act of 1974, disclosure of the Social Security number on this form is mandatory pursuant to N.D.C.C. 247 65-05-02. The Social Security number is used for identification and verification purposes. Failure to provide this information may result in a delay in processing your request. To report an instance of fraud, contact the ND Fraud and Safety Hotline at 800-243-3331. American LegalNet, Inc. www.FormsWorkFlow.com