Claim For Compensation For Line Of Duty Compensation Benefits {WCLoD-1B}

WCLoD-1 (12-17) AI MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS222 COMPENSATION CLAIM FOR COMPENSATION FOR LINE OF DUTY COMPENSATION BENEFITS 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102- 0058 573-526- 4941 www.labor.mo.gov/DWC (Use this form when the injury causing the workers222 death occurred on or after August 28, 2017.) Instructions: 1. Type or print clearly in ink. 2. Claim must be filed by the survivors of the deceased. 3. Last page of this form must be signed by claimant and notarized. 4. If question is not applicable, please answer with N/A. 5. Claim may be filed in person at any of the Division222s adjudication offices or by mail at the address indicated above. 6. Claim must be filed within one year of the date of death of a law enforcement officer, emergency medical technician, air ambulance pilot, air ambulance registered professional nurse, or firefighter killed in the line of duty. FOR DIVISION USE ONLY Case Number: Date Received: A. Pursuant to the provisions of the Line of Duty Compensation Act, 247287.243, RSMo, as amended, application is hereby made for payment of benefits as follows: 1. Decedent222s Name 2. Decedent222s Social Security Number 3. Address of D ec edent222s Missouri residence at time of death 3a. If no Missouri A ddress, please provide the address of decedent222s residence at time of death 4. Date of D eath 5. Date of I njury resulting in death 6. Employer222s Name and A ddress 7. P lac e of I njury causing death 8. Rank and Title of P osition or designation of the position in which decedent was serving at time of death, or at time of injury resulting in death 9. Decedent222s M a rital S tatus at time of death 10. (If applicable) Name, Address, Phone N umber and Social Security Number (last four digits) of decedent222s surviving spouse 11. Did decedent have children? Yes No 12. Please attach copies of the following documents (if available) that provide a full, factual account of the circumstances resu lting in or the course of events causing the decedent222s death: A. Report of Casualty or Accident filed with the employer; B. Certificate of Death; C. Police Report; D. Autopsy Report; E. Medical Records; F. Toxicology Report. 13 . Please attach a copy of a full, factual account that explains the decedent, law enforcement officer, emergency medical technician, air ambulance pilot, air ambulance registered professional nurse, or firefighter died in the act of performance of his or her duties in his or her respective profession. If the decedent222s employer will provide an official statement of the circumstances surrounding the decedent222s fatal injury, please include a copy. Otherwise, please provide a factual written account of the circumstances surrounding the decedent222s fatal injury in so far as is known to the claimant(s) at the time of the filing of this Claim for Compensation for Line of Duty Compensation Benefits. American LegalNet, Inc. www.FormsWorkFlow.com WCLoD-2 (12-17) AI B. Claimant Information 226 A claim shall be filed by survivors of deceased. Please specify below if a claim is being filed by surviving spouse or 223child.224 247287.243.2(3) defines 223child224 as any natural, illegitimate, adopted or posthumous child or stepchild of the deceased who is 18 years of age or younger; or a full-time student at an institution of higher education that meets the definition set forth in 5 U.S.C. Section 8101 and age 22 or younger; or over 18 years of age and incapable of self-support because of physical or mental disability. 1. Claimant222s Name [if surviving spouse, please list your name] 2. Claimant222s Address ( s urviving spouse222s address ) 3. P hone Number Home: Work: 4. Claimant222s Name ( if child, please list child222s name ) (if more than one child, please attach an additional sheets with the child222s name, address and parent or guardian information) 5. Claimant222s Address ( if child, please indicate addres s of parent or natural guardian) 6. P hone Number Home: Work: 7. Pleas e attach the following documents: A. Certified Copy of Marriage Certificate (for surviving spouse) B. Certified Copy of the Birth Certificate for each child claiming benefits or Court Order determining the child222s parentage C. If benefits are being claimed on behalf of a child who is under 18 by a person other than the child222s surviving natural parent, attach a Certified Copy of the Court Order appointing a Guardian for the child and a Certified Copy of the Court Order appointing the claimant as the Conservator of Estate of the child. D. If benefits are being claimed on behalf of a child who is over 18 and disabled, attach a Certified Copy of the Court Order appointing a guardian for the disabled child and a Certified Copy of the Court Order appointing the claimant as the Conservator of the Estate of the disabled child. E. In the case of an illegitimate child, a copy of the court order determining paternity/maternity . C. If you are an individual under executed designation of beneficiary form, or an individual designated on the most recently executed life insurance policy, or a surviving parent or parents, or a child over the age of 18, please complete the information below and attach a copy of the designation of beneficiary form or decedent222s or child222s birth certificate (to show parentage). 1 . Claimant222s Name 2 . Claimant222s Address 3. P hone Number 4. Relationship to D ecedent Home: Work: D. If an estate has been opened, please complete the following information: 1. Relation ship to dece d nt 2. A Petition for Issuance of Letters of Administration was filed In the Circuit Court of County, Probate Division, Estate Number: 3. A full probate administration was not req uired based upon the following: A. Refusal of Letters to surviving spouse or unmarried minor, minor, or dependent children ordered by the Circuit Court; a. County and State: b. Estate Number: B. Determination of Heirship in an intestate case. a. County and State: b. Estate Number: American LegalNet, Inc. www.FormsWorkFlow.com WCLoD-3 (12-17) AI 4. If available and/or applicable, please attach the following documents: A. Certified copy of the Order granting Refusal of Letters to surviving spouse or unmarried minor, minor, or dependent children entered by the Circuit Court; B. Certified copy of the Circuit Court Order on the Determination of Heirship; C. Certified copy of the Circuit Court Order on small estate procedures; D. Certified copy of the Circuit Court Order on Termination of Administration and approval of the final settlement of the estate; E. Court222s Decree of Final Distribution 5. Please attach copies of any other documents that may be relevant or useful in consideration of this claim. 6. P lease check the appropriate box below : I am am not currently represented by an attorney. I agree to notify the Division in writing if and when I hire an attorney to represent me in this case. 7 . Name and Address of the Attorney representing the estate 8. Name and address of the attorney representing the claimant on this Claim for Compensation for Line of Duty Benefits claim: STATE OF ) ) COUNTY OF ) on oath, states that the information in the foregoing application was completed by, or at the direction of, the undersigned and that matters stated therein are true and correct. Claimant222s Signature Subscribed and sworn to before me this day of, 2. Notary Seal Notary Public Please visit the Division222s website at https://labor.mo.gov/DWC/InjuredWorkers/survivorbenefits for additional information relating to Survivor222s Benefits or for a copy of the brochure. A copy of Senate Bill 66, which includes the legislative changes made to the Line of Duty Compensation Program, can be found online at http://www.senate.mo.gov/17info/BTSWeb/Bill.aspx?SessionType=R&BillID=57095462 . American LegalNet, Inc. www.FormsWorkFlow.com