"Beneficiaries' Claim for Compensation" - Montana

Beneficiaries' Claim for Compensation is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • Released on September 1, 2008;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
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INSTRUCTIONS FOR COMPLETING
BENEFICIARIES CLAIM FOR COMPENSATION
Eligible beneficiaries have one year after the date of the employee’s death to file this form to claim death
benefits.
Forms may be found on the Department’s web site listed below or by calling the Employment Relations
Division (406) 444-6543.
Injured Employees - Employees have two reporting requirements:
1. Notify the employer of a work related accident within 30 days of its occurrence; and
2. Submit a First Report of Injury (FROI) or Beneficiaries’ Claim for Compensation Form to
the Employer, Employers’ Insurer or to the Department of Labor and Industry within one
year of the accident.
3. To file an occupational disease claim, submit a FROI or Beneficiaries Claim for
Compensation form to the Employer, Employers’ Insurer or to the Department of Labor
and Industry within one year of the date the Occupational Disease was known.
This should be done for all injuries in order to protect the employees’ right to benefits in the event a
seemingly minor injury develops into a more serious condition.
Employers - Employers must report every work related injury to their insurer within 6 days of notice of
the injury. This report must be submitted even if the employer questions whether the reported accident is
job-related. The form provides space for the employer to fully explain all conditions concerning the
accident or occupational disease, and additional information may be attached.
Eligible Beneficiaries - a surviving spouse; unmarried children under age 18 or age 22 if in school, or in
an accredited apprenticeship program; or a disabled/handicapped child over 18 who was dependent upon
the deceased for support at the time of injury may collectively receive compensation of 2/3 the wages
earned by the deceased at the time of the incident up to the specified maximum amount allowed by law.
Spouse’s benefits cease upon remarriage or at 500 weeks, whichever is first. Survivorship benefits
continue for children meeting the above conditions even if the spouse remarries. A parent (s) dependent
upon the deceased for support at the time of injury may receive compensation of 2/3 of the wages earned
by the deceased at the time of the incident up to the specified maximum amount allowed by law. If there
is no eligible spouse, child or dependent family members, a lump sum death benefit may be paid to non
dependent parents. Please attach a copy of the death certificate and copies of any marriage certificate(s),
divorce decree(s), children’s birth certificate(s), dependent information as defined in 26 U.S.C. 152, or
other documentation that may assist in establishing the eligibility of beneficiaries to expedite the
processing of this claim. All eligible beneficiaries have one year after the date of the employee’s death
to file the beneficiaries form to claim death and burial benefits.
INFORMATION
If you have questions about filling out this form or other workers’ compensation claim-related questions,
please contact us
(406) 444-6543 or visit our website:
www.erd.dli.mt.gov
Department of Labor and Industry
Employment Relations Division
Claims Assistance Bureau
PO Box 8011
Helena MT 59604-8011
(406) 444-6543
INSTRUCTIONS FOR COMPLETING
BENEFICIARIES CLAIM FOR COMPENSATION
Eligible beneficiaries have one year after the date of the employee’s death to file this form to claim death
benefits.
Forms may be found on the Department’s web site listed below or by calling the Employment Relations
Division (406) 444-6543.
Injured Employees - Employees have two reporting requirements:
1. Notify the employer of a work related accident within 30 days of its occurrence; and
2. Submit a First Report of Injury (FROI) or Beneficiaries’ Claim for Compensation Form to
the Employer, Employers’ Insurer or to the Department of Labor and Industry within one
year of the accident.
3. To file an occupational disease claim, submit a FROI or Beneficiaries Claim for
Compensation form to the Employer, Employers’ Insurer or to the Department of Labor
and Industry within one year of the date the Occupational Disease was known.
This should be done for all injuries in order to protect the employees’ right to benefits in the event a
seemingly minor injury develops into a more serious condition.
Employers - Employers must report every work related injury to their insurer within 6 days of notice of
the injury. This report must be submitted even if the employer questions whether the reported accident is
job-related. The form provides space for the employer to fully explain all conditions concerning the
accident or occupational disease, and additional information may be attached.
Eligible Beneficiaries - a surviving spouse; unmarried children under age 18 or age 22 if in school, or in
an accredited apprenticeship program; or a disabled/handicapped child over 18 who was dependent upon
the deceased for support at the time of injury may collectively receive compensation of 2/3 the wages
earned by the deceased at the time of the incident up to the specified maximum amount allowed by law.
Spouse’s benefits cease upon remarriage or at 500 weeks, whichever is first. Survivorship benefits
continue for children meeting the above conditions even if the spouse remarries. A parent (s) dependent
upon the deceased for support at the time of injury may receive compensation of 2/3 of the wages earned
by the deceased at the time of the incident up to the specified maximum amount allowed by law. If there
is no eligible spouse, child or dependent family members, a lump sum death benefit may be paid to non
dependent parents. Please attach a copy of the death certificate and copies of any marriage certificate(s),
divorce decree(s), children’s birth certificate(s), dependent information as defined in 26 U.S.C. 152, or
other documentation that may assist in establishing the eligibility of beneficiaries to expedite the
processing of this claim. All eligible beneficiaries have one year after the date of the employee’s death
to file the beneficiaries form to claim death and burial benefits.
INFORMATION
If you have questions about filling out this form or other workers’ compensation claim-related questions,
please contact us
(406) 444-6543 or visit our website:
www.erd.dli.mt.gov
Department of Labor and Industry
Employment Relations Division
Claims Assistance Bureau
PO Box 8011
Helena MT 59604-8011
(406) 444-6543
BENEFICIARIES’ CLAIM FOR COMPENSATION
MT DEPARTMENT OF LABOR & INDUSTRY
Employment Relations Division
PO Box 8011, Helena MT 59604-8011
(406) 444-6543
Instructions
The claim must be submitted within 12 months from the date of injury or occupational disease (OD) that caused the death. Read each
section carefully and complete those which are applicable. Please submit original signed form to the employer’s insurer or to the Dept. of
Labor & Industry. A letter may be attached to further explain any answer. Provision of the Social Security Number (SSN) is voluntary, per
Privacy Act of 1974, 5U.S.C. 552a. The SSN is used as a key identifier of the claimant. Failure to provide the SSN may delay certain
actions on a claim.
1.
Social Security Number
Full Name of Deceased
Home Address
City
State
Zip Code
Date of Injury/OD
Date of Death
Date of Birth
Age
Employer at Time of Injury/OD
Occupation
Employer’s Address
City
State
Zip Code
2. Spouse of the deceased may claim benefits both for the spouse and minor children (child under the age of 18) of the spouse and the deceased. A
copy of the marriage certificate must be attached. Complete sections 1, 2 and 4.
Full Name of Deceased’s Spouse
Social Security Number
Address
City
State
Zip Code
Check One: At time of injury/OD were you
Living with, or
Separated from but supported by the deceased
3. Guardian or conservator of the children of the deceased may claim benefits on behalf of the minor children. The letter of guardianship,
conservatorship or divorce decree awarding custody must be attached. Complete sections 1, 3 and 4.
Full Name of Guardian or Conservator
Address
City
State
Zip Code
4. List the names and exact birthdates of the deceased’s minor children (children under the age of 18). Include dependent stepchildren and any
child legally adopted by the deceased. Indicate their status by placing an “S” for stepchild and “A” for adopted or an “N” for natural child.
Copies of birth certificates or copies of adoption papers must be attached. Attach extra sheets if necessary.
Full Name
Status ( S, A or N )
Date of Birth
5. Any adult child of the deceased who is unmarried over 18 and under 22 years of age and is a full time student in an accredited school or
apprenticeship program; or a disabled/handicapped child over 18 who was dependent upon the deceased for support at the time of injury/OD may
also be eligible for benefits. If a guardian has submitted a claim for a disabled/handicapped child over 18 no additional claim is necessary.
Complete sections 1 and 5. Attach extra sheet if necessary.
Name of Adult Child over 18 Attending School
Date of Birth
Social Security Number
Address
City
State
Zip Code
Name of Accredited School or Apprenticeship Program
School Address
Name of Disabled/Handicapped Child over 18
Date of Birth
Social Security Number
Address
City
State
Zip Code
6. Dependent parents, brothers or sisters may be eligible for benefits if there are no other individuals entitled to death benefits.
Copies of dependent information as defined in 26 U.S.C. 152 must be attached. Non-dependent parents may receive a lump sum payment if no
other beneficiary exists. Complete sections 1 & 6.
Name of Parent, Brother or Sister
Social Security Number
Address
City
State
Zip Code
I hereby make claim for workers’ compensation benefits due to the death of the above named that died as a result of injuries sustained while working for the
above named employer.
Signature of Beneficiary, Guardian, Conservator, Parent, Brother or Sister ______________________________________________________
Date ___________________
Revised 9/08 - ERD
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