Indiana - Claim for Compensation by Widow, Widower, and Children

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Procedure

Apply In-Person:

1. To Claim for Compensation by Widow, Widower, and Children, the applicant has to approach the U.S. DEPARTMENT OF LABOR Office of Workers' Compensation Programs link
2. The applicant has to download the form from the following link

   Note: The applicant must have an updated version of Adobe Reader to open the application form.

3. The applicant needs give all the information in the application form.
4. Make sure that the applicant has to attach the necessary documents which is mentioned in the “Required Documents” section of this page.
5. The applicant has to attach the photocopies of the required documents along with the application form while submitting.
6. Submit all the documents with the completed form to the concerned officer.
7. The fee for this procedure is free of cost.
8. Once the verification process is done by the officer, the applicant receives the notification through mail or email.
9. The processing time for this procedure is one month.
10. The applicant gets the claim permit through mail.
11. The applicant gets the monthly payment for more details claim payment check the application form 3rd page.

Apply by mail

1. To Claim for Compensation by Widow, Widower, and Children, the applicant has to approach the U.S. DEPARTMENT OF LABOR Office of Workers' Compensation Programs link
2. The applicant has to download the form from the following link

   Note: The applicant must have an updated version of Adobe Reader to open the application form.

3. The applicant needs give all the information in the application form.
4. Make sure that the applicant has to attach the necessary documents which is mentioned in the “Required Documents” section of this page.
5. The applicant has to attach the photocopies of the required documents along with the application form while submitting.
6. Submit all the documents with the completed form to the respective state offices.
7. The state office address is mentioned in the “Office Locations & Contacts” section of this page.
8. The fee for this procedure is free of cost.
9. Once the verification process is done by the officer, the applicant receives the notification through mail or email.
10. The processing time for this procedure is one month.
11. The applicant gets the claim permit through mail.
12. The applicant gets the monthly payment for more details claim payment check the application form 3rd page.

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Required Documents

• Application form link
• Deceased employee birth certificate
• Deceased employee death certificate
• The marriage certificate(s) for a widow or widower.
• Death certificate for decedent if not Are Required previously submitted
• Birth certificate or adoption documents for each child.
• Letter of Guardianship. If either the decedent or the surviving spouse was previously married, legal documents showing dissolution of such prior marriage(s).
• Copies of certificates or documents are acceptable only if they are certified by the person having official custody of such records.

Office Locations & Contacts

INDIANA
Workers' Compensation Board of Indiana
402 West Washington Street
Room W-196
Indianapolis, IN 46204
(317) 232-3811 or (800) 824-2667
Website link
Contact link
Regional office link

Eligibility

Widow or Widower

• To qualify for benefits, a widow or widower must have been living with the employee or separated for reasonable cause prior to the time of death. Payments continue for life or until remarriage. Upon remarriage, a widow or widower will receive a lump sum equal to 24 times his or her monthly compensation. If the remarriage occurs at age 60 or later, no lump sum is paid. Instead, payments continue for life.

Children

• Eligible children include natural, adopted, step and posthumous children unmarried and under 18 years of age. Payments continue beyond 18 if the child is incapable of self-support because of mental or physical incapacity. Payments also continue on behalf of children over 18 if they are full-time students. Student benefits terminate on: marriage, completion of four years of education beyond high school level, or at age 23, whichever occurs first.

Fees

• The fee for the procedure is free of cost.

Validity

Explain the time until which the certificate/document is valid.
e.g. Birth Certificate Valid Forever

Documents to Use

• Application form link

Sample Documents

Please attach sample completed documents that would help other people.

Processing Time

• The processing time for this procedure is up to one month.

Related Videos

Videos explaining the procedure or to fill the applications.
Attach videos using the following tag <&video type='website'>video ID|width|height<&/video&>
from external websites.
Please remove the '&' inside the tags during implementation.
Website = allocine, blip, dailymotion, facebook, gametrailers, googlevideo, html5, metacafe, myspace, revver,
sevenload, viddler, vimeo, youku, youtube
width = 560, height = 340, Video ID = Can be obtained from the URL of webpage where the video is displayed.
e.g In the following url 'http://www.youtube.com/watch?v=Y0US7oR_t3M' Video ID is 'Y0US7oR_t3M'.

Instructions

• Applicant must complete the application form before submitting. Incomplete applications will not be accepted.
• Applicant must provide genuine information while applying for this procedure.

Required Information

• Name of deceased employee
• DOB
• Date of injury
• Date of death
• Social security number
• Name and address of employing agency
• Nature of injury which caused death
• Name of dependent
• Dependent's address (Include ZIP Code)
• Dependent's birth date
• Dependent's Occupation
• Dependent's Social Security Number
• Dependent's relationship to employee
• Extent of dependency on employee
• Total amount employee contributed to dependent's support during 12 months immediately prior to death.
• Did employee live with dependent during the 12 months immediately prior to death?
• Information about dependent's husband or wife
• Attending Physician's Report

Need for the Document

• This claim form should be completed and filed by the widow or widower for self and surviving children. If there is no surviving widow or widower, the children's guardian completes the claim

Information which might help

Compensation Rates

• For widows or widowers - 50% of the employee's monthly pay if there are no surviving eligible children - 45% if there are eligible children.
• Children - 15% each, not to exceed a total of 30%, shared equally if there is a widow or widower; if there is no widow or widower, 40% for one child plus 15% for each additional child, shared equally. Monthly payments for all beneficiaries cannot exceed 75% of the employee's monthly pay rate, or 75% of the top step of GS-15 of the General Schedule.
• Federal payments are made through Direct Deposit. Therefore, a, completed Form SF-1199A, Direct Deposit Sign-up must be submitted with Form CA-5

For More Information link

Other uses of the Document/Certificate

Please explain what are other uses of obtaining this document/certificate.
e.g. Birth Certificate can be used as proof of identity.

External Links

Link
Link

Others

• Funeral and burial allowance expense up to a maximum of $800 may be paid. Amount paid by the VA will be deducted. If death occurs away from the employee's duty station, transportation costs may be paid to return the deceased employee to his home or last place of residence. In addition to any funeral or burial expenses, a sum of $200 may be paid for reimbursement of the costs of termination of the decedent's status as an employee of the United States.