Fill and Sign the Tx Notice Injury Form

28. Full Name Mailing Address Birth Date Full Time Student Marital Status Social Security Number                                                                                                                                                Yes No No Yes      Carrier's Claim #                         American Indian, Aleut or Eskimo Female White, not of Hispanic origin Black, not of Hispanic origin Hispanic Asian or Pacific Islander Other No Yes If yes, please provide name and address in next block and attach copy of marriage certificate to this                                                                                                                                16. How long had employee worked for this employer? Months             Hour Day Week                   Amount                               No If no, Separated                         Yes       Send to Field Office Handling Claim, TWCC# if known orTEXAS WORKERS' COMPENSATION COMMISSION4000 South IH - 35, Southfield BuildingAustin, Texas 78704 Si prefiere hablar con una persona de hablahispana acerca de esta correspondencia o desu reclamo, sirvase Ilamar al 1-800-252-7031. NOTICE OF FATAL INJURY OR OCCUPATIONAL DISEASE AND CLAIM FOR COMPENSATION FOR DEATH BENEFITSIf 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 with the Texas Workers' Compensation Commission no later than one year after the employee's death to protect your claim for entitlement to deathbenefits. 1. Full Name of Deceased Employee (Last, First, M.I.) 2. Date of Birth 3. Social Security Number 4a. Sex of Deceased 4b. Race or Ethnic Background. Please check applicable box. This will be used for statistical purposes only. Male 5a. Was employee married at the time of death? 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. 5b. Spouse's Name (Last, First, M.I.) 6a. Employer's Company's Business Name 5c. Spouse's Mailing Address Street or P.O. Box 6b. Employer's Mailing Address and Telephone Number Street or P.O. Box City State ZIP Code City County State ZIP Code INJURY OR DISEASE INFORMATION 7. Date of Injury 8. Date of Death 9. County of Injury 10. If injury occurred outside of Texas, on what date did employeeleave Texas? 11. Cause of Death 12. Describe Cause of Injury 13. If accident occurred outside of Texas, give: County State 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 15b. Mailing Addresses of Witnesses(Street or P.O. Box) City State ZIP Code A. A B. B. Years 17. Was employee hired or recruited in Texas? WAGE INFORMATION 18. Average Weekly Wage 19. Average Hours Worked Daily 20. Average Days Worked Weekly 21. Rate of Pay: (Mark One) SPOUSE INFORMATION 22. Full Name of Beneficiary and Social Security Number 23. Telephone Number 24. Relationship to Deceased 25. Date of Birth 26a. Were employee and spouse living together during 26b. If not living together, were employee and spouse: 26c. If separated, how long were employee and spouse the year before death? Yes separated? 26d. Was spouse: hospitalized in a nursing home living apart due to career or military service living apart pending divorce OTHER BENEFICIARY INFORMATION 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. 29a. Name and Social Security Numberof Person Who Has Custody of Children 29b. Mailing Address (Street or P.O. Box) 30. If widow, is a childexpected? No City State ZIP Code If yes, when? COMPLETE AND SIGN THE REVERSE SIDE OF THIS FORM TWCC-42 (Rev. 12/99) Page 1 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 Security Number 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                   $                         $                         $       No                                                 No             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 Has any of this bill been paid? Yes Amount Paid By Whom$ $ 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.) 37a. Physician's Name 37c. Total Medical Bills $ 37b. Physician's Mailing Address (Street or P.O. Box) Amount of Unpaid Bills $ Cit y State ZIP Code 37d . Autopsy Performed Yes EACH PERSON MUST FILE A SEPARATE CLAIM FOR DEATH BENEFITS UNLESS THE CLAIM EXPRESSLY INCLUDES OR IS MADE ON BEHALF OF ANOTHER PERSON. Signature of Beneficiary Dat e Signature of Witness Dat e (Only when signed with an X) TWCC-42a (Rev. 12/99) Page 2 of 2 TEXAS WORKERS' COMPENSATION COMMISSION