Fill and Sign the Arizona Claim Benefits Form

Yes No If yes state details and provide copies of divorce SPOUSESPOUSE WITH DEPENDENT CHILDREN DEPENDENT CHILDREN PARENTS OTHER DEPENDENTS BURIAL EXPENSE ONLY Name of Deceased:       Soc. Sec. # *-       Date of Birth:       Date of Death:       Date of Injury: (If different from date of death):       Deceased's Address:             Employer at time of death:       Employer's address:                         Your Full Name:       Date of Birth:             Date of Marriage to Deceased:       Place of Marriage:             BEFORE THE INDUSTRIAL COMMISSION OF ARIZONA CLAIM FOR DEPENDENT'S BENEFITS - FATALITY CHECK APPROPRIATE BOX: (Must be filed by guardian) INFORMATION REGARDING DECEASED: 1 . 2. 3. 4. 5. 6. Briefly state cause of death: 7. List name and address of health care providers that treated deceased in the last two years and state condition treated: CLAIM FOR SPOUSAL BENEFITS: (Provide certified copy of marriage certificate.) 1 . 2. Your Address: 3. 4. Were You or Deceased Married Previously? decrees. (Rev. 5/00) Yes No If living apart provide reason, such as divorced, Yes No If yes Provide anticipated date of delivery: Full Partial                                                                                                                               Which of these children are still in your care and custody?                   Name:             Relationship to Deceased:       Please give details:                         5. Did you reside with deceased at time of death?divorce pending, annulment, abandonment. CLAIM FOR DEPENDENT CHILDREN: (Provide certified copies of birth certificates .) 1 . List dependent children: NAM E DATE OF RELATIONSHIP ADDRESS AT TIME OF DEATH BIRT H TO DECEASED 2. 3 Is a Posthumous (unborn) child expected? OTHER DEPENDENTS: 1 . 2. Address: 3. 4. Extent of Dependency: DATE SIGNATURE OF/OR ON BEHALF OF DEPENDENT TELEPHONE NUMBER To be filed at either office of the Industrial Commission: Phoenix Industrial Commission of Arizona800 W. Washington StreetPhoenix, Arizona 85007-2922 Tucson Office: Office: Industrial Commission of Arizona2675 E. BroadwayTucson, Arizona 85716-5342 P. 0. Box 19070Phoenix, Arizona 85005-9070 11 The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted bySection 7(a) (2) (B) of the Federal Privacy Act of 1974, because the Commission's forms, prescribed under the Commission's Rules in existence prior to January I , 1 975, required disclosure of thesocial security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbersis made necessary because of the large number of persons who have similar names and birth dates, and whose identifies can only be distinguished by the social security number. THE INDUSTRIAL COMMISSION COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT OF 1990. IF YOU NEED THIS DOCUMENT IN ALTERNATIVE FORMAT, CONTACT SPECIAL SERVICES AT (602) 542-1829.