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(APPLICATION FOR DEATH BENEFITS PURSUANT TO THE LINE (Illinois Attorney General)

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(APPLICATION FOR DEATH BENEFITS PURSUANT TO THE “LINE OF DUTY COMPENSATION ACT”)
COURT OF CLAIMS - STATE OF ILLINOIS
630 South College
Springfield, IL 62756
APPLICATION FOR BENEFITS
Pursuant to provisions of the "Line of Duty Compensation Act” (820 ILCS 315, et seq.),
application is hereby made for payment of benefits on account of the death of:
As follows:
1. Name of decedent:
2. Address of decedent’s Illinois residence at time of death:
3. Address at time of entry into the United States Armed Forces (if on active duty as an
Armed Forces member):
4. Place of birth:
5. Date of death:
6. Date of injury resulting in death:
7. Branch of Service (if on active duty as an Armed Forces member):
8. Employer and employer's address (if not an Armed Forces member):
.
9. Rank and title of position or assignment in which decedent was serving at the time of
death or at the time of injury resulting in death:
2
10. Decedent's Social Security Number:
11. Name(s) and address(es) of beneficiary, or beneficiaries, designated by decedent on Line
of Duty Compensation Act Designation of Beneficiary Form for receipt of benefits.
Include all Social Security Numbers. Cash amount or Percentage share
12. For claims for deaths of Armed Forces members on active duty, attach copies of the
following Department of Defense documents (if available):
A. Report of Casualty (DD Form 1300)
B. Certificate of Death (DD Form 2064)
C. Record of Emergency Data (DD Form 93)
D. Servicemember 's Group Life Insurance Election and Certificate
(SGLV8222)
13. Attach copies of any other form or forms on which decedent designated beneficiaries for
receipt of death benefits. Provide social security numbers of every beneficiary so
designated.
14. What was the decedent's marital status at the time of death?
15. If applicable, state the name, address, phone number and social security number of
decedent's surviving spouse.
16. Did decedent have children?
3
17. If applicable, state the names, addresses, phone numbers, social security numbers and
birthdates of decedent's children.
18. State the name(s), address(es), phone number(s) and social security number(s) of the
other parent(s) of the child or children listed in the answer to question 17, above.
19. If decedent left no surviving spouse or children, state the names, addresses, phone
numbers and social security numbers of decedent's surviving parents.
20. If decedent left no surviving spouse, children, or parents, state the name(s),
address(es)phone number(s) and social security number(s) of decedent's next of kin.
Also, state their relationship to decedent.
21. Attach copies of any other documents (eg: incident or investigation reports, statements,
4
newspaper articles, obituaries) which explain the circumstances involved in the
decedent's death.
22. Attach copies of any other documents you believe may be relevant or useful in
consideration of this claim.
23. If decedent was on active duty as a member of the United States Armed Forces, state the
name, address and phone number of the Military Casualty Assistance Officer assigned to
assist you with matters relating to decedent's death.
24. If decedent was not on active duty as an Armed Forces Member, state the name, title,
employer, address and phone number of decedent's supervisor at the time of decedent's
death.
5
(APPLICATION FOR BENEFITS PURSUANT TO THE "LINE OF DUTY COMPENSATION ACT")
Name of Applicant:
Address:
Relationship, if any, to decedent:
Applicant's Social Security Number:
Date of Application:
STATE OF )
)
COUNTY OF )
, on oath, states that the information in
the foregoing application was completed by, or at the direction of, the undersigned and that
matters stated therein are true and correct.
Applicant's Signature
Subscribed and sworn to
before me this day
of , 2 .
NOTARY PUBLIC
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(APPLICATION FOR DEATH BENEFITS PURSUANT TO THE LINE (Illinois Attorney General)

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Completed 13 August 2020

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