Get Online 262 Form

The Online 262 Form is utilized to claim death benefits under various compensation acts overseen by the U.S. Department of Labor. This guide offers clear and concise instructions for completing the form, ensuring you provide the necessary information to facilitate your claim.

Follow the steps to accurately complete your Online 262 Form.

1. Click the ‘Get Form’ button to access the Online 262 Form and open it in your preferred editor.
2. Begin by entering the name of the deceased employee in the designated field, including their first name, middle initial, and last name.
3. Fill in the last known address of the deceased, providing the complete street address, city, state, and ZIP code.
4. Next, input the name and address of the employer, including the street number, city, state, and ZIP code.
5. Enter the date of death in the specified format. This field is crucial for the claim process.
6. Provide details regarding the place where the injury occurred, ensuring to include specific information.
7. Enter the date of injury, followed by a description of the nature of the injury or occupational illness along with the cause of death.
8. Input the name and address of the undertaker responsible for handling the deceased, along with the total amount of the undertaker's bill.
9. Indicate the amount paid towards the funeral expenses and the place of death.
10. Specify the name and address of the last attending physician or hospital. This information is essential for verifying treatment.
11. Fill out the name of the person responsible for paying the undertaker's bill.
12. Complete the section for the widow or widower, including full name, address, Social Security number, date of birth, nationality, and other relevant marriage details.
13. List all children of the deceased, providing their full names, addresses, Social Security numbers, dates of birth, and relationships.
14. Include information about other dependent individuals, ensuring to provide their details in the required format.
15. Review all entered information for accuracy and completeness before proceeding.
16. Finally, save your changes, download, print, or share the completed form as necessary.

To file your claim efficiently, ensure you complete the Online 262 Form accurately and submit it online.