Claim For Death Benefits - Longshore Act Form LS-262.pdf

Claim for Death Benefits (Form LS-262)

This form is used to apply for death benefits under various US workers' compensation acts, including:

Longshore and Harbor Workers' Compensation Act (LHWCA)
Defense Base Act (DBA)
Outer Continental Shelf Lands Act (OCSLA)
Nonappropriated Fund Instrumentalities Act (NFI).

Key Information Required:

- Deceased Employee: Name, SSN, date of birth, death date, last address.
- Employer: Name, address, and identification number.
- Undertaker: Full name and address.
- Relationship to Deceased: Widow/Widower, children (names, dates of birth, SSNs), other dependents.
- Nature of Injury/Illness: Description of injury or illness leading to death, affected body parts.
- Medical Information: Last attending physician or hospital name and address.
- Financial Information: Income for one year prior to death, dependent's support amount and source (if applicable).
- Claimant Information: Name, address, SSN, nationality, date of birth (for guardian).
- Date of Injury & Death: Exact dates.
- Place of Incident/Death: Specific street address or location description.

Eligibility:

Benefits are payable to:

- Widow or widower if married to the deceased at the time of death.
- Unmarried children under 18, or over 18 who were wholly dependent on the deceased and unable to support themselves due to disability.
- Other dependents meeting legal dependency requirements (grandchildren, brothers/sisters, parents, grandparents).

Time Limit:

Claims must be filed within:

- One year of the employee's death for most cases.
- Two years from the date the claimant becomes aware of the relationship between employment and death due to an occupational disease.

Consequences of False Statements:

Making false statements to obtain benefits under these acts is a felony punishable by up to $10,000 fine or five years in prison, or both.