Can I e-sign the claim?

Yes. Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted; ensure the claimant consents to electronic records and the platform captures an audit trail demonstrating intent, attribution, and retention.

Are notarization or witnesses required?

Requirements depend on document type and jurisdiction; some affidavits and proofs may need notarization or witnesses. Check local probate and court rules before filing to avoid rejection.

What if the claimant lacks probate appointment?

Without letters testamentary or administration, a claimant may lack authority to settle estate claims; obtain court appointment or work with an appointed representative to proceed.

How long must I keep documents?

Retain records for the active period plus applicable federal minima: e.g., IRS-relevant documents 3 years from filing, HIPAA-related records 6 years (45 CFR §164.530(j)). State rules may require longer retention.

Can remote notarization be used?

Remote Online Notarization (RON) is permitted in most states under state law; verify your state’s RON rules and ensure audio-video recording and identity proofing meet local requirements.

What happens if I miss a filing deadline?

Missing statutory or administrative deadlines can bar recovery or lead to claim denial; consult counsel promptly to evaluate tolling, equitable exceptions, or late-filing remedies.

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Claim for Compensation in a Death Case

Claim for Compensation in a Death Case

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State of New York - Workers' Compensation Board
Claim for Compensation in a Death Case

This claim will be processed more quickly if copies of necessary documents are submitted to the Board. Attach copies of the documents which you have in your possession. Otherwise obtain copies and bring them to the first hearing. DO NOT DELAY filing this claim form. Necessary documents are as follows:

a. A medical report from doctor who treated the deceased.

b. Death certificate.

c. Proof of relationship such as birth certificate, marriage certificate, adoption papers, etc.

d. Itemized funeral bill.

W.C.B. CASE NO. (if known)

CARRIER CASE NO.

DECEDENT'S SOC. SEC. NO.

CLAIMANT'S SOC. SEC. NO.

DECEASED NAME AND ADDRESS (Give No., Street, City, State and Zip Code)

EMPLOYER NAME AND ADDRESS

CARRIER NAME AND ADDRESS

CLAIMANT NAME AND ADDRESS

I hereby make claim under the Workers' Compensation Law for compensation arising out of the death of the deceased named above as the result of injury sustained in the employ of the above named employer, and, in support of this claim submit the following information:

1a. Date of death

1a. Time and place of death

1b. How did accident or occupational disease happen?

1c. Place of accident

1d. Nature of injury and part(s) of body injured

2. Attending physician

3. Last physician or hospital

4. Undertaker

5. Person who paid undertaker bills

6. Amount of undertaker's bills

Amount paid, if any

7. Claimant's date of birth

8. Relationship to deceased

9. Is deceased survived by a spouse and/or children under 18 years of age or under 23 years of age and enrolled and attending as full-time students in any accredited educational institution?

Yes No

10. Survivors or dependents of the deceased

11-14. Additional information as applicable

If you are the spouse or child of the deceased

a. Date married to deceased

Place

Person performing ceremony

b. Number of children under 18 years of age at time of death

c. Number of children ages 18 to under 23, enrolled and attending full time

Share of survivor's insurance benefits under Social Security Act

If you are neither spouse nor child under 18 or under 23 and enrolled full time

a. Were you wholly or partially dependent on the deceased for support?

b. If partially dependent, to what degree?

c. Real estate owned

d. Other sources of income

If you are a child or dependent student

Name of student

Name and address of educational institution

Date attendance began

Dated

Signed by (Claimant's Signature)

Telephone No.

Signed by (A person on behalf of Claimant)

Relationship

Telephone No.

Notification Pursuant to the New York Personal Privacy Protection Law and the Federal Privacy Act of 1974.

The Workers' Compensation Board's authority to request personal information from claimants is derived from Sections 20 and 142 of the Workers' Compensation Law. This information is collected to assist the Board in processing claims in an efficient manner and to help it maintain accurate claim records.

The Board is strongly committed to protecting the confidentiality of all personal information that it collects. Such information will be disclosed within the agency only to Board personnel and agents in furtherance of their official duties. Personal information will be disclosed outside the agency only in accordance with applicable state and federal law.

Failure to provide the information requested on this form will not result in the denial of your claim, but may delay the processing of your claim. The voluntary release of your social security number enables the Board to ensure that information is associated with, and quick action is taken on, your claim.

NY Statewide Fax Line

What a Claim for Compensation in a Death Case Is

A Claim for Compensation in a Death Case is a formal legal document filed by an estate representative, beneficiary, or claimant seeking monetary relief for losses resulting from a deceased person's injury or death. Typical contexts include wrongful death claims, survival actions, and administrative claims against government programs or insurers. The claim identifies the decedent, the claimant, the legal basis for compensation, a statement of damages, and any supporting facts or evidence. Properly completed claims establish the claimant's standing and create a record the opposing party, insurer, or court uses to evaluate liability and damages.

Why a Clear Claim Matters for Compensation Outcomes

A well-constructed Claim for Compensation in a Death Case clarifies who may recover, the legal theory invoked, and the relief sought, which reduces delays and lowers the risk of dismissal. It preserves legal rights, starts statutory timelines, and creates a paper trail that supports settlement negotiations or court proceedings.

Who Typically Prepares and Submits This Claim

Typical filers include personal representatives, beneficiaries, next of kin, and counsel acting on their behalf.

Personal representatives or executors preparing claims to protect estate interests and satisfy probate duties.
Surviving family members or named beneficiaries asserting wrongful death or survival action claims.
Attorneys representing claimants who draft complaints, gather evidence, and manage litigation or negotiations.

Filing parties should confirm they have authority to act and check state-specific probate or wrongful death statutes before submission.

Key People Involved

Personal Representative

The estate fiduciary appointed by a probate court or named in the will who files claims on behalf of the decedent's estate and manages distribution of any recovery; must follow probate deadlines and duty-of-care obligations.

Wrongful Death Attorney

A licensed attorney who evaluates liability and damages, prepares pleadings, negotiates with insurers, and represents the claimant in court; counsel often ensures statutory notices and filing rules are met.

Core Sections to Include in the Claim

A professional Claim for Compensation in a Death Case contains defined sections that present parties, facts, legal basis, and damages in a structured manner.

Caption

Court or administrative caption identifying parties, case number (if assigned), and venue so the claim is properly routed and docketed.

Parties

Full legal names and capacities (e.g., personal representative, beneficiary), addresses, and contact information for each claimant and defendant.

Statement of Facts

Concise chronological narrative of events that led to the decedent's injury or death, including dates, locations, and active participants.

Legal Theories

Citations to the governing statutory or common-law cause of action, such as wrongful death, survival action, negligence, or intentional tort.

Damages

Specific categories and quantitative estimates of economic loss, funeral expenses, medical costs, lost earnings, and non-economic damages where allowed.

Supporting Evidence

List of documents attached or available: death certificate, medical records, accident reports, bills, employment records, and witness statements.

Step-by-Step: Completing the Claim Form

Follow these steps to assemble a complete, submission-ready Claim for Compensation in a Death Case.

01

Gather documents: Collect death certificate, medical records, bills, and employment records.
02

Confirm authority: Verify personal representative appointment or beneficiary status with probate documents.
03

Draft factual narrative: Write a clear chronology of events and link evidence to each assertion.
04

Complete fields: Enter names, dates, damage amounts, and attach supporting PDFs.

Typical Submission and Review Workflow

A Claim for Compensation in a Death Case usually follows an upload, review, and adjudication process, whether filed with an insurer, agency, or court.

Prepare: Assemble claim and PDFs, verify signatory authority.
Submit: Send claim to insurer, claims adjuster, or court clerk per filing rules.
Acknowledge: Recipient issues a confirmation and may request further documentation.
Adjudicate: Investigation, negotiation, or court proceedings resolve liability and damages.

Configure an Online Workflow for the Claim

When using an e-submission platform, set up fields and routing to match internal review and signature steps.

Field	Configuration
Claimant Signature	Require signature + date field with signer email verified
Executor Upload	Allow required PDF uploads for probate orders
Routing Order	Sequence: claimant -> attorney -> insurer or court
Notifications	Email alerts for pending actions and completed submissions

Technical Considerations for eSubmission and eSignatures

Use a platform that supports secure uploads, audit trails, and the authentication level your jurisdiction or counterparty requires.

File formats: PDF, DOCX supported
Authenticator options: Email, SMS, or KBA
Security: TLS in transit, AES-256 at rest

Ensure the platform complies with ESIGN/UETA and any industry rules such as HIPAA; retain the audit trail for future proof of execution.

Key Timing Considerations and Deadlines

Different claims and jurisdictions impose distinct deadlines; track statute of limitations and administrative notice periods carefully.

Statute of Limitations:

Varies by state and claim type; often 1–3 years for wrongful death claims.

Probate Filings:

File documents required by the probate court per local rules after appointment.

Insurance Notice:

Provide prompt notice to carriers as required by policy to preserve coverage.

Discovery Deadlines:

Comply with court-issued deadlines after complaint filing.

Retention Start Date:

Dates in the claim trigger retention obligations for records.

Common Mistakes to Avoid When Preparing a Claim

Incomplete authority documentation: Failing to attach probate appointment or letters testamentary often results in administrative rejection or delay.
Vague damage estimates: Listing non-specific amounts without supporting invoices or calculations weakens settlement or filing positions.
Missing or unorganized evidence: Sending scattered or illegible records causes repeated follow-up and slows claims processing.
Incorrect signatory details: Using an unsigned or improperly authorized signer can render the claim ineffective or subject to challenge.

Risks and Consequences of an Incorrect or Untimely Claim

Statute bar: Loss of legal remedy

Claim denial: Insurer rejects for procedural defects

Financial exposure: Estate may incur costs or reduced recovery

Sanctions: Court may impose fees for improper filings

Reputational harm: Delays and disputes can strain family relations

Evidence loss: Missing records reduce proof of damages

Sample Scenarios: How a Completed Claim May Look

Two anonymized examples illustrate common claim formats and documentation bundles for death-related compensation.

Case Example 1

A personal representative files a survival action after a traumatic injury

Claim lists medical bills totaling $120,000 and lost wages
The submission includes a certified death certificate, itemized hospital invoices, employment records, and a sworn statement linking the injury to the decedent's death, reducing follow-up requests.

Case Example 2

A beneficiary pursues wrongful death damages against a vehicle operator

Claim quantifies funeral costs of $10,000 and economic loss estimates
Supporting materials include police report, medical examiner report, proof of relationship, and an affidavit from the claimant establishing dependency and financial loss.

Representative Signatories and Their Roles

Executor

An executor named in the decedent's will who is authorized to file claims and enter settlements on behalf of the estate; must provide probate appointment and may need court approval for certain settlements.

Claimant Attorney

Counsel authorized by written retainer to file and prosecute claims who handles notices, discovery, settlement negotiations, and ensures procedural compliance.

Frequently Asked Questions About Claims and eSignatures

Answers to common procedural and legal questions about preparing and submitting a Claim for Compensation in a Death Case, including e-signature considerations.

Need help? Contact support

Can I e-sign the claim?
Yes. Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. §7001) and UETA where adopted; ensure the claimant consents to electronic records and the platform captures an audit trail demonstrating intent, attribution, and retention.
Are notarization or witnesses required?
Requirements depend on document type and jurisdiction; some affidavits and proofs may need notarization or witnesses. Check local probate and court rules before filing to avoid rejection.
What if the claimant lacks probate appointment?
Without letters testamentary or administration, a claimant may lack authority to settle estate claims; obtain court appointment or work with an appointed representative to proceed.
How long must I keep documents?
Retain records for the active period plus applicable federal minima: e.g., IRS-relevant documents 3 years from filing, HIPAA-related records 6 years (45 CFR §164.530(j)). State rules may require longer retention.
Can remote notarization be used?
Remote Online Notarization (RON) is permitted in most states under state law; verify your state’s RON rules and ensure audio-video recording and identity proofing meet local requirements.
What happens if I miss a filing deadline?
Missing statutory or administrative deadlines can bar recovery or lead to claim denial; consult counsel promptly to evaluate tolling, equitable exceptions, or late-filing remedies.

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