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This document is a supplementary application form for individuals who were dependents of a deceased worker and are applying for workers' compensation benefits due to a compensable dust disease.

How to fill out supplementary application form by

How to fill out Supplementary application form by dependant of deceased worker for workers’ compensation benefit

1. Obtain the Supplementary application form from the workers' compensation board or relevant authority.
2. Fill out the personal information section with your name, address, and contact details.
3. Provide details of the deceased worker, including their name, date of birth, and date of death.
4. Indicate your relationship to the deceased worker in the specified section.
5. Complete any required information regarding the worker's employment and the circumstances of their death.
6. Gather supporting documentation such as death certificates and proof of relationship.
7. Review the completed form for accuracy and completeness.
8. Submit the form along with any required supporting documents to the appropriate workers' compensation office.

Who needs Supplementary application form by dependant of deceased worker for workers’ compensation benefit?

1. Dependants or family members of a deceased worker who seek benefits under workers' compensation due to the worker's death.

For pdfFiller’s FAQs

What is Supplementary application form by dependant of deceased worker for workers’ compensation benefit?

The Supplementary application form by dependant of deceased worker for workers’ compensation benefit is a document that allows dependants of a deceased worker to apply for additional compensation benefits. This form is typically required when a worker has died due to a work-related injury or illness, providing dependants with access to financial support.

Who is required to file Supplementary application form by dependant of deceased worker for workers’ compensation benefit?

Dependants of a deceased worker, such as spouses, children, or other eligible family members, are required to file the Supplementary application form to claim compensation benefits following the worker's death resulting from a work-related incident.

How to fill out Supplementary application form by dependant of deceased worker for workers’ compensation benefit?

To fill out the Supplementary application form, dependants should provide accurate personal information, details regarding the deceased worker’s employment, the nature of the injury or illness that caused death, and any additional required documentation to support the claim, such as proof of relationship to the deceased.

What is the purpose of Supplementary application form by dependant of deceased worker for workers’ compensation benefit?

The purpose of the Supplementary application form is to ensure that dependants of deceased workers receive appropriate financial compensation for loss of income and support due to the work-related death of their loved one, facilitating the claims process for benefits.

What information must be reported on Supplementary application form by dependant of deceased worker for workers’ compensation benefit?

The information that must be reported includes the deceased worker's personal details, the specifics of the work-related injury or illness, information about dependants making the claim, and any relevant financial details showing the impact of the worker's death on the dependants' livelihoods.