Application For Death Benefits Pursuant To Line Of Duty Compensation Act {CC-92}

Illinois Court of Claims Secretary of State Illinois Court of Claims, 630 S. College St., Springfield, IL 62756 Application for Death Benefits Pursuant to Line of Duty Compensation Act Pursuant to provisions of the Line of Duty Compensation Act, application is hereby made for payment of benefits on account of the death of: ____________________________________________________________________________________ 1. Name of Decedent: _________________________________________________________________________________________ 2. Address of decedent's Illinois residence at time of death: _____________________________________________________ 3. Address at Time of Entry into the U.S. Armed Forces (if on active duty as an Armed Forces member): _______________ ____________________________________________________________________________________________________________ 4. Place of Birth: ______________________________________________________________________________________________ 5. Date of Death: ______________________________________________________________________________________________ 6. Date of Injury Resulting in Death: ___________________________________________________________________________ 7. Branch of Service (if on active duty as an Armed Forces member):_____________________________________________ 8. Employer and Employer's Address (if not an Armed Forces member): _______________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 9. Rank and Title of Position or assignment in which decedent was serving at time of death or at time of injury resulting in death: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 10. Name(s) and Address(es) of all beneficiaries designated by decedent on Line of Duty Compensation Act Designation of Beneficiary Form for receipt of benefits: Name Address $ amount or % share ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 11. Attach a copy of Line of Duty Designation of Beneficiary form: _______________________________________ 12. For claims on deaths of Armed Forces members on active duty, attach copies of the following Department of Defense documents (if available): A. Report of Casualty (DD Form 1300) B. Certificate of Death (DD form 2064) (if available) C. Record of Emergency Data (DD Form 93) (if available) D. Servicemember's Group Life Insurance Election and Certificate (SGLV8222) 13. If the decedent left a will, please attach a copy of it. Provide social security numbers and current addresses of every beneficiary designated in the will. 14. Attach copies of any other form(s) on which decedent designated beneficiaries for receipt of death benefits. Printed by authority of the State of Illinois. December 2016 -- 1 -- CC 92.4 American LegalNet, Inc. www.FormsWorkFlow.com 15. Decedent's Marital Status at time of death: ___________________________________________________________________ 16. (If applicable) Name, Address and Phone Number of decedent's surviving spouse: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 17. Did decedent have children? K Yes K No 18. (If applicable) Name(s), Address(es), Phone Number(s) and Birthdates of decedent's children: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 19. Name(s), Address(es) and Phone Number(s) of other parent(s) of child or children listed in 16: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 20. (If decedent left no surviving spouse or children) Name(s), Address(es) and Phone Number(s) of decedent's surviving parents: _____________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 21. (If decedent left no surviving spouse, children or parents) Name(s), Address(es) and Phone Number(s) of decedent's nextof-kin and relationship to decedent: ____________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 22. Attach copies o