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Death and Funeral Benefits Application OCF - 4 Return this form to Use this form for accidents that occur on or after January 1 1994 Claim Number Policy Number Date of Accident YYYYMMDD This form must be completed by or on behalf of the spouse and dependant s of the deceased and any other person entitled to claim for benefits. Please print clearly. Part 1 Deceased s Information Marital or Same-Sex Partner Status Single Separated Married Divorced .

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