"Petition to Determine Compensation Due to Dependents of Deceased Employee" - Delaware

Petition to Determine Compensation Due to Dependents of Deceased Employee is a legal document that was released by the Delaware Department of Labor - a government authority operating within Delaware.

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Download "Petition to Determine Compensation Due to Dependents of Deceased Employee" - Delaware

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PETITION TO DETERMINE COMPENSATION DUE TO DEPENDENTS
OF DECEASED EMPLOYEE
To the Industrial Accident Board of the State of Delaware
Sitting in and for
County
Claimant SS#
}
Claimant (Deceased Employee)
Date of Birth
vs.
Insurance Carrier
Employer
Case File No.
The undersigned petitioner respectfully represents:
That the above named claimant and the above named employer have failed to reach
an agreement in regards to compensation due said claimant as the dependent of
a deceased employee of said employer.
The undersigned therefore prays that your Honorable Board shall, after due notice of
the time and place of hearing served on all parties in interest, hear and determine the matter in
accordance with the facts and the law and state its conclusions of fact and rulings of law.
Dated this
day of
A.D. 20
.
Witness:
Name:
Signature
Signature
Print Name
Print Name
Document Control #: B60-07-12-12-11
PETITION TO DETERMINE COMPENSATION DUE TO DEPENDENTS
OF DECEASED EMPLOYEE
To the Industrial Accident Board of the State of Delaware
Sitting in and for
County
Claimant SS#
}
Claimant (Deceased Employee)
Date of Birth
vs.
Insurance Carrier
Employer
Case File No.
The undersigned petitioner respectfully represents:
That the above named claimant and the above named employer have failed to reach
an agreement in regards to compensation due said claimant as the dependent of
a deceased employee of said employer.
The undersigned therefore prays that your Honorable Board shall, after due notice of
the time and place of hearing served on all parties in interest, hear and determine the matter in
accordance with the facts and the law and state its conclusions of fact and rulings of law.
Dated this
day of
A.D. 20
.
Witness:
Name:
Signature
Signature
Print Name
Print Name
Document Control #: B60-07-12-12-11
INDUSTRIAL ACCIDENT BOARD
STATE OF DELAWARE
Statement of Facts Upon Failure to Reach an Agreement
1. Name of Employee
Address
City____________________________ State______________ Zip__________________
Telephone Number __________________E-mail (optional) ______________________
2. Date of Accident ________________ 3. Place of Accident
4. Name of Employer
Employer Contact Name_______________________ E-mail (optional)_____________
Address
City____________________________ State _______________ Zip _______________
Telephone Number _____________________Fax #_____________________________
rd
5. Name of Insurance Carrier / 3
Party Administrator_________________________________
6. Occupation of employee at the time of accident
7. Nature of accident and how it happened
8. Describe the nature of injury
9. Did employee receive medical, surgical or hospital service?
Yes
No
10. When was notice of injury given to or received by employer?
11. Give names and addresses of all employers for the last 5 years. If more space is needed,
attach a separate sheet.
NAME:
ADDRESS:
12. State weekly wage when injured
13. State names and addresses of all treating doctors for this claim. If more space is needed,
attach a separate sheet.
NAME:
ADDRESS:
14.
State number of weeks employed during the last twelve months
15.
State at what trade or occupation employed during the last twelve months
16.
Date of death
17.
What were the expenses of last sickness and burial
18.
Amount of these expenses paid by the employer
19.
Name of widow or widower of deceased, if dependent
20.
Names and dates of birth of dependent children under sixteen years of age.
21.
Names and addresses of surviving father and mother of deceased, if dependent.
22.
Give names and dates of birth of dependent sibling(s) of deceased under sixteen years of
age.
23.
State any other important facts bearing on the case above presented.
Dated: _______ Day of _______________, 20______
I swear or affirm that the information contained
in this statement is true and correct to the best
of my knowledge and recollection. I
___________________________________________
understand and acknowledge that any
Dependent Signature
falsehood contained in this statement may
expose me to civil or criminal liability.
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