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
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
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?