Affirmation For Death Benefits {AFF-1}

AFF-1 - AFFIRMATION FOR DEATH BENEFITS. This affidavit is to be used by a surviving spouse or the dependent child(ren) of the deceased; by dependent brothers/sisters/grandchildren; by dependent parents/grandparents. It can also be used by the non-dependent parents or the estate of the deceased where there is no surviving spouse or other dependents. The law provides up to $12,500 for funeral expenses downstate, and $10,500 upstate, depending on the county where the expenses are incurred. The law also provides weekly benefits up to a maximum amount, based on the date of accident, for the following: (a) the legal surviving spouse until the spouse remarries, (b) Decedent's children up to age 18 (age 23 if they are attending an accredited educational institution as a full-time student), and (c) any dependent children of any age who are totally blind or totally and permanently disabled. If there is no legal surviving spouse or dependent children, the law provides weekly benefits to grandchildren or siblings under age 18 who were dependent upon Decedent for support; or to parents or grandparents who were dependent upon Decedent for support when Decedent died. If there are no individuals entitled to weekly death benefits, then $50,000 may be paid to Decedent's parents, or to Decedent's estate if Decedent's parents are deceased. If you receive money as a result of a wrongful death action, the law allows the insurer to have a lien or credit against that money. The insurer's lien and credit rights may affect your ability to receive workers' compensation benefits until the lien and/or credit is exhausted. It is important to advise the insurer of the status of a wrongful death action, and to obtain its consent prior to settlement. www.FormsWorkflow.com