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The undersigned petitioner respectfully represents: That the above named claimant and the above named employer have failed to reach. Having received notice of an injury, you must now complete the First Report of Injury form and submit it to your workers' compensation insurance carrier.If a worker dies due to a workrelated injury and leaves no surviving dependents, the employer is not liable for the cash payments. Petition to Determine Compensation Due to Dependents of Deceased. Employee. Payments to your spouse, children, or other dependents if you die from a job injury or illness. Payments to your spouse, children, or other dependents if you die from a job injury or illness. Death benefit payments are made to surviving total and partial dependents of the deceased. Complete Worker's Compensation Guide. Give the application to the personnel office. If a worker dies due to a workrelated injury and leaves no surviving dependents, the employer is not liable for the cash payments.