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DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATIONAGREEMENT FOR COMPENSATION FOR DEATH DECEASED’S SOCIAL SECURITY NUMBER OR WC ID NUMBER - - - - DATE OF INJURY WCAIS CLAIM NUMBER MM DD YYYY DECEASED EMPLOYEE EMPLOYER First name Last name Date of birth MM DD YYYY Date of death MM DD YYYY DEPENDENT/GUARDIAN/PERSONAL REPRESENTATIVE First name Last nameAddressAddress City/Town State ZIP County Telephone INJURY INFORMATION Part of body injuredNature of injury Accident/injury description narrative Check if occupational disease Name AddressAddressCit y/T own State ZIP County Telephone FEIN INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) NameAddressAddress City/Town State ZIP County Telephone FEINContactNAIC code or Insurer code Insurer/TPA claim # NOTICE: Agreement should be clearly completed, (preferably typed) and uploaded in accordance with the provisions of EDI Implementation Guide. A copy must be sent to the dependent/guardian/personal representative. Wage information must be completed in accordance with Section 309 of the Pennsylvania Workers’ Compensation Act, and sent to the Dependent/ Guardian/Personal Representative. We, the following persons, dependents of the aforementioned deceased employee, and the undersigned employer, agree upon the following matters which determine dependents’ rights to compensation and its amount and duration. Employer Representative’s signature NAME RESIDENCEDATE OF BIRTH MM-DD-YYYY RELATIONSHIP - - - - LIBC-338 REV 09-13 (Page 1) . The compensation payable under the agreed facts, based on the average weekly wage of $ , is as follows: $ $ $ $ $ $ $ $ $ $ $ $ $ $ - - - - MM DD YYYY - - MM DD YYYY Compensation was paid beginning and ending for the employee’s disability prior to death. WEEKLY RATE FROM MM-DD-YYYY THROUGH MM-DD-YYYY #WEEKS/#DAYS REASON FOR CHANGE AMOUNT Amount expended for medical $ Amount expended for burial $ Further matters agreed upon: Date of agreement MM DD YYYY Dependent/Guardian/Personal Representative’s signature Claims Representative’s signature Claims Representative’s name (typed/printed) Telephone Any individual �ling misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud) Employer Information Services 717.772.3702 Claims Information Services toll-free inside P A: 800.482.2383 local & outside PA: 717.772.4447 Hearing Impaired toll-free inside PA T TY: 800.362.4228 local & outside PA T TY: 717.772.4991 Email ra-li-bwc -helpline@pa.go v *338* Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-338 REV 09-13 (Page 2)