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Payment workers compensation 2026
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- Click ‘Get Form’ to open the payment workers compensation document in the editor.
- Begin by entering the Deceased Employee's Social Security Number and their full name in Part B. Ensure accuracy as this information is crucial for processing.
- Fill in the Date of Injury, Street Address, City, State, and Zip Code of the deceased employee. This helps establish the context of the claim.
- In the Benefits section, specify the weekly benefit amount and average weekly wage. Make sure to include any penalties if applicable.
- List all total dependents along with their addresses and dates of birth. If there are partial dependents, complete that section only if no total dependents exist.
- Finally, review all entered information for accuracy before signing and dating the form. Remember to file the original with the State Board of Workers' Compensation.
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