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To file a claim, complete the "Employee" section of the form, keep one copy and give the rest to your employer. This chapter describes procedures for developing and adjudicating death claims under the FECA.Who can receive Workers Compensation (WC) benefits? Eligible beneficiaries must complete DWC Form-042, Beneficiary Claim for Death Benefits and send it to DWC within one year from the date the employee died. Notice to Administrative Law Judge and Employee of Intention to Contest Employee's Right to Compensation Benefits. Temporary total disability (TT):. You will need to fill out your part of the C-4 form the first time you visit a medical provider for treatment of your work injury. An injured worker who is temporarily unable to work also receives partial wage replacement payments. Workers' Compensation Dependents' Death Benefits - Notices to Dependents. You will need to fill out your part of the C-4 form the first time you visit a medical provider for treatment of your work injury.