Fill and Sign the Send to Field Office Handling Claim Form

Send to Field Office Handling Claim, Si prefiere hablar con una persona de hablahispana acerca de esta correspondencia o de su reclamo, sirvase Ilamar al 1-800-252-7031. TWCC# if known orTEXAS WORKERS' COMPENSATION COMMISSION 4000 South IH - 35, Southfield Building Austin, Texas 78704 Carrier's Claim # NOTICE OF FATAL INJURY OR OCCUPATIONAL DISEASE AND CLAIM FOR COMPENSATION FOR DEATH BENEFITS If you are a beneficiary of an employee who died from an on-the-job injury or occupational disease, you or your representative must file this form withthe Texas Workers' Compensation Commission no later than one year after the employee's death to protect your claim for entitlement to deathbenefits. 2. Date of Birth 3. Social Security Number 1. Full Name of Deceased Employee (Last, First, M.I.) 4a. Sex of Deceased 4b. Race or Ethnic Background. Please check applicable box. This will be used for statistical purposes only. American Indian, Aleut or Eskimo Male Female Asian or Pacific Islander Other White, not of Hispanic origin Black, not of Hispanic origin Hispanic 5a. Was employee married at the time of death? No Yes If yes, please provide name and address in next block and attach copy of marriage certificate to this this form. If yes, additional information is required in Blocks 22 through 26 below. A common law marriage maybe recognized. Proof of the relationship must be submitted. 6a. Employer's Company's Business Name 5b. Spouse's Name (Last, First, M.I.) 5c. Spouse's Mailing Address Street or P.O. Box 6b. Employer's Mailing Address and Telephone Number Street or P.O. Box State ZIP Code State ZIP Code City City County INJURY OR DISEASE INFORMATION 8. Date of Death 7. Date of Injury9. County of Injury 11. Cause of Death 12. Describe Cause of Injury 13. If accident occurred outside of Texas, give: State County Country 14a. If death was the result of an occupational disease, explain how the disease was caused by employment. 14b. On what date was the employee last exposed to cause of the disease? 15a. Names of Witnesses State ZIP Code City 15b. Mailing Addresses of Witnesses(Street or P.O. Box) A.A B. B. 17. Was employee hired or recruited in Texas? Years 16. How long had employee worked for this employer? Months Yes No WAGE INFORMATION 18. Average Weekly Wage 19. Average Hours Worked Daily 20. Average Days Worked Weekly 21. Rate of Pay: (Mark One) Hour Week Day Month Amount SPOUSE INFORMATION 25. Date of Birth 22. Full Name of Beneficiary and Social Security Number 23. Telephone Number 24. Relationship to Deceased 26a. Were employee and spouse living together during 26c. If separated, how long were employee and spouse 26b. If not living together, were employee and spouse:separated? Divorced Separated the year before death? Yes No If no, explain: 26d. Was spouse: hospitalized in a nursing home living apart due to career or military service living apart pending divorce OTHER BENEFICIARY INFORMATION No Yes 27. Were any children born of this marriage If yes, list all children in Block 28. Attach an additional page, if needed. For children 25 years of age or younger, attach a copy of each child's birth certificate. For adult dependent children, attach documentation of dependency. 30. If widow, is a child 29b. Mailing Address (Street or P.O. Box) 29a. Name and Social Security Numberof Person Who Has Custody of Children expected? No Yes State ZIP Code City If yes, when? COMPLETE AND SIGN THE REVERSE SIDE OF THIS FORM TWCC-42 (Rev. 12/99) Page 1 of 2 10. If injury occurred outside of Texas, on what date did employeeleave Texas? 28. Full Name Mailing Address Birth Date Full Time Student Marital Status Social Security Number Prior Marriages Children 25 Years of Age or Younger of Prior Marriages (Attach copy of birth certificate for each child listed.) Dependent Grandchildren Dependent Parents (if employee was unmarried.) Other Dependents If employee was unmarried and parents not dependent, list brothers, sisters, or grandparents dependent on employee.) Burial Benefits 36. Amount of funeral bill Amount Paid By Whom No Has any of this bill been paid? Yes $ $ The person claiming burial benefits must file a request for payment and attach the bills showing funeral expenses and transportation costs. The request with attachments must be filed with the insurance carrier within 12 months of the employee's death. If the compensable injury occurred on or before August 31, 1999, the maximum due for burial costs payable by the insurance carrier is $2,500. If the compensable injury occurred on or after September 1, 1999, the maximum due for burial costs payable by the insurance carrier is $6000. Medical Information (Attach copy of death certificate.) 37c. Total Medical Bills 37a. Physician's Name $ 37b. Physician's Mailing Address (Street or P.O. Box) Amount of Unpaid Bills $ State ZIP Code City 37d. Autopsy Performed Yes No EACH PERSON MUST FILE A SEPARATE CLAIM FOR DEATH BENEFITS UNLESS THE CLAIM EXPRESSLY INCLUDES OR IS MADE ON BEHALF OF ANOTHER PERSON. Date Signature of Beneficiary Date Signature of Witness (Only when signed with an X) TWCC-42a (Rev. 12/99) TEXAS WORKERS' COMPENSATION COMMISSION Page 2 of 2 31. Spouse's Full Name Mailing Address, If Known Date of Divorce or Death 32. Full Name Mailing Address Birth Date Full Time Student Marital Status Social Security Number 33. Full Name Mailing Address Social SecurityNumber Monthly Contribution $ $ $ 34. Parent's Full Name Mailing Address Social Security Number Monthly Contribution Father $ Mother $ 35. Name Mailing Address Social Security Number Monthly Contribution $ $ $