West Virginia - Claim for Compensation by Parents, Brothers, Sisiters, GrandParents, or GrandChildren

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Procedure

Apply In-Person:

1. To Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren, the applicant has to approach the U.S. DEPARTMENT OF LABOR Office of Workers' Compensation Programs link
2. The applicant has to download the form from the following link
3. The applicant needs give all the information in the application form.
4. Make sure that the applicant has to attach the necessary documents which is mentioned in the “Required Documents” section of this page.
5. The applicant has to attach the photocopies of the required documents along with the application form while submitting.
6. Submit all the documents with the completed form to the concerned officer.
7. The fee for this procedure is free of cost.
8. Once the verification process is done by the officer, the applicant receives the notification through mail or email.
9. The processing time for this procedure is one month.
10. The applicant gets the claim permit through mail.
11. The applicant gets the monthly payment for more details claim payment check the application form 3rd page.

Apply by mail

1. To Claim for Compensation by Parents, Brothers, Sisters, Grandparents, or Grandchildren, the applicant has to approach the U.S. DEPARTMENT OF LABOR Office of Workers' Compensation Programs link
2. The applicant has to download the form from the following link
3. The applicant needs give all the information in the application form.
4. Make sure that the applicant has to attach the necessary documents which is mentioned in the “Required Documents” section of this page.
5. The applicant has to attach the photocopies of the required documents along with the application form while submitting.
6. Submit all the documents with the completed form to the respective state offices.
7. The state office address is mentioned in the “Office Locations & Contacts” section of this page.
8. The fee for this procedure is free of cost.
9. Once the verification process is done by the officer, the applicant receives the notification through mail or email.
10. The processing time for this procedure is one month.
11. The applicant gets the claim permit through mail.
12. The applicant gets the monthly payment for more details claim payment check the application form 3rd page.

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Required Documents

• Application form link
• Deceased employee birth certificate
• Deceased employee death certificate
• Birth certificates for minor brothers, sisters and grandchildren
• If claim is made on behalf of a grandparent, birth certificate of decedent's mother or father.
• If claim is made on behalf of a grandchild, birth certificate of decedent's son or daughter

NOTE: Copies of certificates or documents are acceptable only if they are certified by the person having official custody of such records. then they should be attached to the claim form when it is filed.

Office Locations & Contacts

WEST VIRGINIA
Office of the Insurance Commission
900 Pennsylvania Avenue
Charleston, WV 25302
mailing address:
P.O. Box 50540
Charleston, WV 25305-0504
(304) 558-3386 or (888) 879-9842
Website link
Contact link

Eligibility

• Any person who is a deceased employee's parents, grandparents or representative (custodian or guardian) of minor brothers, sisters or grandchildren are eligible to make this application.

Fees

• The fee for the procedure is free of cost.

Validity

Explain the time until which the certificate/document is valid.
e.g. Birth Certificate Valid Forever

Documents to Use

• Application form link

Sample Documents

Please attach sample completed documents that would help other people.

Processing Time

• The processing time for this procedure is up to one month.

Related Videos

Videos explaining the procedure or to fill the applications.
Attach videos using the following tag <&video type='website'>video ID|width|height<&/video&> from external websites.
Please remove the '&' inside the tags during implementation.
Website = allocine, blip, dailymotion, facebook, gametrailers, googlevideo, html5, metacafe, myspace, revver,
sevenload, viddler, vimeo, youku, youtube
width = 560, height = 340, Video ID = Can be obtained from the URL of webpage where the video is displayed.
e.g In the following url 'http://www.youtube.com/watch?v=Y0US7oR_t3M' Video ID is 'Y0US7oR_t3M'.

Instructions

• Applicant must complete the application form before submitting. Incomplete applications will not be accepted.
• Applicant must provide genuine information while applying for this procedure.

Required Information

• Name of deceased employee
• DOB
• Date of injury
• Date of death
• Social security number
• Name and address of employing agency
• Nature of injury which caused death
• Name of dependent
• Dependent's address (Include ZIP Code)
• Dependent's birth date
• Dependent's Occupation
• Dependent's Social Security Number
• Dependent's relationship to employee
• Extent of dependency on employee
• Total amount employee contributed to dependent's support during 12 months immediately prior to death.
• Did employee live with dependent during the 12 months immediately prior to death?
• Information about dependent's husband or wife
• Attending Physician's Report

Need for the Document

• To applying this claim, the applicant get the Benefits are payable on behalf of partially or totally dependent parents, brothers, sisters, grandparents and grandchildren. The complete claim is done by labour department. A separate form is required for each person claiming benefits.

Information which might help

• For More Information link

Other uses of the Document/Certificate

Please explain what are other uses of obtaining this document/certificate.
e.g. Birth Certificate can be used as proof of identity.

External Links

Link
Link

Others

• Funeral and burial allowance expense up to a maximum of $800 may be paid. Amount paid by the VA will be deducted. If death occurs away from the employee's duty station, transportation costs may be paid to return the deceased employee to his home or last place of residence. In addition to any funeral or burial expenses, a sum of $200 may be paid for reimbursement of the costs of termination of the decedent's status as an employee of the United States.