Instructions:
4. Under item 16(b), state all your income for the year preceding
death by source (Social Security pension, bonds, etc.) and amount.
List separately support deceased furnished you, including the value of
any shelter, food, clothing, or other supplies. Use space below or
additional sheets if needed.
1. Use this form to claim death benefits under the Longshore and
Harbor Workers' Compensation Act, Defense Base Act, Outer Con-
tinental Shelf Lands Act, or Nonappropriated Fund Instrumentalities
Act. The information provided will be used to determine
entitlement to benefits.
5. A person other than the claimant may complete claim for the
beneficiary.
2. Submit claim in duplicate to a district office of the Office of
Workers' Compensation Programs (OWCP).
6. Persons are not required to respond to this collection of information
unless it displays a currently valid OMB number.
3. individual claims must be filed by or in behalf of each person
eligible for benefits [33 U.S.C. 913(a)]. (included are grandchildren,
brothers and sisters under 18 years, parents, step-parents, parents
by adoption, parents-in-laws, and any person who for more than
one year prior to the employee's death stood in place of a parent
to him/her.)
Conditions of Eligibility
What terminates widow's or widower's benefits?
1. Death
Coverage for Death Benefit
2. Remarriage, in which case the widow or widower receives a lump
sum payment of two year's compensation.
A death benefit is payable under the Longshore Act, or related law, if
a covered employee dies as a result of work-related injury or
occupational disease.
What evidence is needed to support a claim?
Who is eligible for a Death Benefit?
1. Widow or widower. Proof of marriage to deceased worker. If
either party was married before, proof that earlier marriage was
legally ended. A certified copy of the final divorce decree, or proof of
death of a previous marriage partner may be required before benefits
are paid. Certified copy of the death certificate of the deceased
worker.
1. The deceased worker's widow or widower living with or dependent
for support at the time of death; or widow or widower living apart for
good cause or because of desertion by worker.
2. Unmarried child(ren) under age 18, or if over 18: (a) was (were)
wholly dependent on deceased worker and unable to support
self(ves) because of mental or physical disability, or (b) student(s) up
to age 23 (must meet certain requirements). Includes a posthumous
child, legally adopted child, child to whom deceased acted as parent
for one year before injury, stepchild, or acknowledged illegitimate
child.
2. Children - Certified copy of birth certificate or Order of Adoption. If
a legal guardian has been appointed, a certified copy of the Letters of
Guardianship.
Time requirement of filing claim
3. If the combined amount due a surviving widow or widower and
child or children is not greater than two-thirds (66 and 2/3 percent) of
the worker's average weekly wages subject to a maximum benefit of
200 percent of the national average weekly wage, a benefit is
payable for any one of the following: Grandchildren, brothers or
sisters (if dependent at time of injury), parents, grandparents, or others
satisfying legal requirements of dependency. (Consult the Office of
Within one year of employee's death. The time may not begin to run,
however, until the person claiming the benefit would reasonably have
related the employee's death to his or her employment. In case of
death due to an occupational disease, a claim may be filed within two
years after the claimant becomes aware, or in the exercise of
reasonable diligence or by reason of medical advice should have
been aware, of the relationship between the employment, the disease
Workers' Compensation Programs for more information.)
and the death.
Use the space below or a separate sheet of paper to continue answers. Please number each answer to correspond to the number
of the item being continued.
Note: The notice applies to all forms requesting information that you might receive from the Office in connection with the processing and/or
adjudication of the claim you filed under the LHWCA and related statutes.
Public Burden Statement
We estimate that it will take an average of 15 minutes to complete this collection of information, including time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these
estimates or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the U.S. Department of Labor,
Division of Longshore and Harbor Workers' Compensation, Room C4315, 200 Constitution Avenue, N.W., Washington, DC 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
Privacy Act Notice
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a) you are hereby notified that (1) the Longshore and Harbor Workers' Compensation Act,
as amended and extended (33 U.S.C. 901 et seq.) (LHWCA) is administered by the Office of Workers' Compensation Programs of the U.S. Department of Labor,
which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to determine
eligibility for and the amount of benefits payable under the LHWCA. (3) Information may be given to the employer which employed the claimant at the time of
injury, or to the insurance carrier or other entity which secured the employer's compensation liability. (4) Information may be given to physicians and other
medical service providers for use in providing treatment or medical/vocational rehabilitation, making evaluations and for other purposes relating to the medical
management of the claim. (5) Information may be given to the Department of Labor's Office of Administrative Law Judges (OALJ), or other person, board or
organization, which is authorized or required to render decisions with respect to the claim or other matter arising in connection with the claim. (6) Information may
be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the LHWCA, to determine whether
benefits are being or have been paid properly, and, where appropriate, to persue salary/administrative offset and debt collection actions required or permitted by
law. Disclosure of the claimant's Social Security Number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN and other
information maintained by the Office may be used for identification, and for other purposes authorized by law. (8) Failure to disclose all requested information may
delay the processing of the claim, the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.
