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FORM FDA 3500A SUPPLEMENT
Death: Check if death was an outcome of the adverse event, or if the cause of the death is unknown. Include the date of death, if known. Hospitalization (
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Ill. Admin. Code tit. 80, 1540.90 - Benefit Offset
a) Occupational Disability, Occupational Death, and Survivors annuity. Any amounts received under the Workers Compensation Act [820 ILCS 305 ] or the
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820 ILCS 315/ Line of Duty Compensation Act.
Sec. 3.5. Burial benefit. A burial benefit of up to a maximum of $20,000 shall be payable to the surviving spouse or estate of a law enforcement officer or
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