Act Pursuant to provisions of the Line of Duty Compensation Act, application is hereby made for payment of benefits on account of the death of: 1. Name of Decedent: 2. Address of decedent s Illinois residence at time of death: 3. Address at Time of Entry into the U.S.
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How to fill out the IL CC 92.3 online
The IL CC 92.3 form is an application for death benefits pursuant to the Line of Duty Compensation Act. This guide provides comprehensive, step-by-step instructions to assist users in completing the form online accurately and efficiently.
Follow the steps to complete the IL CC 92.3 form online.
- Click ‘Get Form’ button to obtain the form and access it in the online editor.
- Fill in the name of the decedent in the designated field. Ensure that the spelling matches official documents for accuracy.
- Provide the decedent’s address in Illinois at the time of their death. This is important for verification purposes.
- Specify the address where the decedent was living when they entered the U.S. Armed Forces, if applicable.
- Complete the place of birth section by indicating the city and state.
- Input the date of death in the required format, using a calendar tool if available.
- Clearly state the date of the injury that resulted in death.
- Specify the branch of service if the decedent was on active duty, or input the employer's information if not.
- Detail the rank and title of the position the decedent held at the time of their death or injury.
- Enter the decedent’s Social Security number, ensuring accuracy to avoid processing delays.
- Provide names, addresses, and Social Security numbers of all beneficiaries as designated on the Line of Duty Compensation Act Designation of Beneficiary Form.
- Attach a copy of the Line of Duty Designation of Beneficiary form by uploading it through the online form.
- If applicable, submit the necessary Department of Defense documents, such as the Report of Casualty.
- Attach a copy of the will if the decedent left one, including details of all designated beneficiaries.
- Include any additional documents that may support the claim, as outlined in the form.
- Verify marital status of the decedent at the time of death.
- If relevant, provide details about the decedent’s surviving spouse, including their contact information.
- Indicate if the decedent had children and fill in their details if applicable.
- If there are other parents of the decedent’s children, provide their names and contact information.
- If no surviving spouse or children exist, list the surviving parents or next-of-kin as applicable.
- Include the name and contact information of the military casualty assistance officer, if applicable.
- Finish the form by reviewing all entered information for accuracy and completeness.
- Finally, save your changes, download a copy for your records, and submit the form as instructed.
Start completing your IL CC 92.3 form online today to ensure timely processing of your application.
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