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Application for Adjustment of Claim in Case of Death Due to Occupational Disease. Application For Adjustment Of Claim In Case Of Death Due To Occupational Disease Form.This is a Ohio form and can be use in Employers Workers Comp. (1) Complete Form CA-674, which is a checklist with a section which applies specifically to death cases. Application to uninsured employer's fund for certain claims for exposure to asbestos. -34. Time for claiming compensation for occupational disease. (3) The procedure for filing occupational disease claims shall be as follows: (a) The application for resolution of claim shall set forth the complete work. Death benefits are payments to a spouse, children or other dependents if an employee dies from a work-related injury or illness. Death resulting from accident or occupational disease. In 1992, occupational diseases were estimated to cause roughly 49,000 to 74,000 deaths (Leigh et al. 1997).