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CLAIM for VOLUNTEER FIREFIGHTERS' BENEFITS in a DEATH CASE Wcb Ny Form
Or
b. Death certificate.
malfunction of the heart or of one or more
c. Proof of relationship such as birth certificate, marriage certificate, adoption papers, etc.
coronary arteries?
d. Itemized funeral bill.
Yes
No
W.C.B. CASE NO. (if known)
CARRIER CASE NO.
CARRIER CODE NO.
DECEDENT'S SOC. SEC. NO. CLAIMANT'S SOC. SEC. NO.
NAME
DATE OF ACCIDENT
ADDRESS (Give No, Street,City, State and Zip Code)
Apt. No.
DECEASED
VOLUNTEER
FIREFIGHTER
FIRE COMPANY
POLITICAL
SUBDIVISION
LIABLE FOR...
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