Get the free Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee

This document serves to notify that workers' compensation benefits have been discontinued due to the death of an employee and provides instructions for heirs and dependents regarding potential claims.

How to fill out notice of discontinuance of

How to fill out Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee

1. Obtain the Notice of Discontinuance form from your state's workers' compensation board or relevant authority.
2. Fill in the employee's full name, date of birth, and claim number in the designated fields.
3. Indicate the date of the employee's death in the appropriate section.
4. Provide the reason for discontinuance, which should relate to the employee's death.
5. Include any necessary supporting documentation, such as a death certificate or related legal documents.
6. Sign and date the form at the bottom to certify the information is accurate.
7. Submit the completed form to the workers' compensation board and notify any relevant parties, such as beneficiaries.

Who needs Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee?

1. Insurance carriers managing workers’ compensation claims
2. Employers who are legally required to file a notice after an employee's death
3. Dependents or beneficiaries of the deceased employee (for their records)

For pdfFiller’s FAQs

What is Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee?

The Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee is a formal document filed to terminate the workers' compensation benefits that were being provided to an employee who has died.

Who is required to file Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee?

Typically, the employer or the insurance carrier responsible for the workers' compensation benefits is required to file the Notice of Discontinuance upon the death of the employee.

How to fill out Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee?

To fill out the Notice of Discontinuance, one must provide pertinent information such as the employee's name, date of death, the reason for discontinuance, and other relevant details as specified by the local workers' compensation board or agency.

What is the purpose of Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee?

The purpose of the Notice of Discontinuance is to officially communicate the cessation of benefits due to the death of the employee, ensuring legal compliance and proper record-keeping.

What information must be reported on Notice of Discontinuance of Workers' Compensation Benefits Upon Death of Employee?

The information that must be reported usually includes the employee's name, claim number, date of death, the effective date of discontinuance, and the reasons for the cessation of benefits.