To obtain a workers’ compensation death benefit, survivors should complete/submit the following forms:
- Main Application Form — “Application for Adjudication of Claim (Death Case)”— and any supporting documents requested by the form
- Document Cover Sheet
- Document Separator Sheet
- Proof of Service
If helpful, you may request assistance from a Division of Workers’ Compensation information and assistance officer.
Once the above forms are submitted, within 4-6 weeks, the survivor will receive a response from the Department of Industrial Relations stating that they are issuing an order to the insurance company to approve the claim or, if objections arise, there will be a request for a hearing.
The insurance company has 30 days to comply after receiving the order, then installments are paid/sent bi-weekly.
NOTE: If the surviving family can demonstrate financial hardship, they may appeal for a one-time lump sum instead of installments after the above forms are submitted. This is initiated by submitting a “Petition for Commutation of Future Payments” form, after the survivor receives the initial determination.