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Notice of Discontinuance of Workers’
Compensation Benefits Upon Death of
WID or SSN
DATE OF INJURY
EMPLOYEE (last, first, mi)
B D 0 2
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INSURER CLAIM NUMBER
THIS IS NOTIFICATION THAT WORKERS’ COMPENSATION BENEFITS HAVE BEEN DISCONTINUED UPON THE DEATH
OF THE EMPLOYEE ON
INSURER: PLEASE ANSWER THE FOLLOWING QUESTION(S)
1. Was the employee’s death related to the work-related injury?
Insurer: If yes, please contact the heirs and dependents as soon as possible, and file a new First Report of Injury (with
regard to the death) with the Workers’ Compensation Division
2. If the employee was receiving periodic permanent partial disability, impairment compensation, or economic recovery
compensation at the time of death, will this compensation continued to be paid to the heirs or dependents?
If yes, for how long?