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For Grant Seekers

Filing a Workers' Compensation Death Benefits' Claim

To obtain a workers' compensation death benefit, an eligible survivor or their legal representative should complete and submit the below-linked forms. If helpful, you may request assistance from a Division of Workers’ Compensation information and assistance officer.

• Main Application Form -- “Application for Adjudication of Claim (Death Case)”-- and any supporting documents requested by the form.
• Document Cover Sheet
• Document Separator Sheet
• Proof of Service
• Declaration

Once the above forms are submitted, within 4-6 weeks, the survivor will receive a response from the Department of Industrial Relations stating that they are issuing an order to the insurance company to approve the claim or, if objections arise, there will be a request for a hearing.

The insurance company has 30 days to comply after receiving the order, then installments are paid/sent bi-weekly.

NOTE: If the surviving family can demonstrate financial hardship, they may appeal for a one-time lump sum instead of installments after the above forms are submitted. This is initiated by submitting a “Petition for Commutation of Future Payments” form, after the survivor receives the initial determination.