Get Form 027 Application Death Odc 3.1.12.doc - Laborcommission Utah

Filling out the Form 027 Application Death Odc 3.1.12.doc is an essential process for claiming dependent’s benefits and burial allowances due to occupational disease. This guide provides a detailed, step-by-step approach to assist users in accurately completing the form online.

Follow the steps to successfully complete the application form.

1. Click the ‘Get Form’ button to access the form and open it in your editor.
2. Begin by entering the name of the petitioner at the top of the form in the 'Petitioner' section.
3. In the 'Decedent' section, provide the name of the deceased individual.
4. Complete the 'Respondent' section with the name of the employer, followed by the employer's mailing address, city, state, zip code, and phone number.
5. Fill in the 'Respondent’s workers’ comp Insurance Carrier' portion with the name of the insurance carrier and their mailing address, including city, state, and zip code.
6. Indicate whether you wish to schedule a Claims Resolution Conference by checking the appropriate box in the 'Request' section.
7. In the 'Alleges' section, provide details regarding the occupational exposure, including the dates, location, and nature of the exposure.
8. Specify the cause of death in the designated area.
9. Record the decedent's date of death and their wage details, including how many hours they worked per week and their marital status.
10. List the dependents of the decedent in the indicated format, providing relationship, birth date, present address, and social security number.
11. Ensure that the petitioner signs and dates the form and provides their mailing address, phone number, and email address.
12. Compile required supporting documents, including the decedent's death certificate, documents proving dependency, minor dependents' birth certificates, and any necessary guardianship documents.
13. Before finalizing, review the completed form for accuracy, save your changes, and prepare for submission.

Complete your documents online today to take the next steps in the claims process.