Fill and Sign the Alaska Workers Compensation Board Alaska Dept of Labor Form

ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 DEATH BENEFITS REPORT AWCB Case Number: Complete this form and attach to Compensation Report (Form 07-6104) wh\ en you begin, change, suspend or terminate death benefits payments. 3. Date of Injury 6. Place of Death 1. Deceased Employee's Name (Last, First, Middle Initial) 4. Date of Death 5. Social Security Number 7. Date of Birth 8. Employer 10. Address City StateZip Code Telephone 2. Insurer Claim Number 11. Address 9. Insurer 12. WIDOW(ER) AND/OR CHILDREN: City Zip Code State Telephone a. Name (Last, First Middle Initial) Date of Birth Weekly Rate Date Benefits Terminated Address CityStateZip Code b. Name (Last, First Middle Initial) Date of Birth Weekly Rate Date Benefits Terminated Address City StateZip Code c. Name (Last, First Middle Initial) Date of Birth Weekly Rate Date Benefits Terminated Address CityStateZip Code d. Name (Last, First Middle Initial) Date of Birth Weekly Rate Date Benefits Terminated Address CityStateZip Code e. Name (Last, First Middle Initial) Date of Birth Weekly Rate Date Benefits Terminated Address CityStateZip Code 13. DEPENDENT PARENTS, GRANDCHILDREN, BROTHER(S) AND/OR SISTER(S): a. Name (Last, First Middle Initial) Date of Birth Weekly Rate Date Benefits Terminated Address CityStateZip Code b. Name (Last, First Middle Initial) Date of Birth Weekly Rate Date Benefits Terminated Address CityStateZip Code c. Name (Last, First Middle Initial) Date of Birth Weekly Rate Date Benefits Terminated Address City StateZip Code This is to certify that the original Death Benefits Report and the Compe\ nsation Report (Form 07-6104) have been mailed to all dependents at th\ e above address(es), and copies have been mailed to the Alaska Workers' Compen\ sation Board. 14. Name and Title of Person Submitting Report (Print or Type) 15. Signature 16. Report Date 17. Address CityStateZip Code Telephone Form 07-6118 (Rev 04/2010)