Maritime Claim for Death Benefits Under the Longshore Act

To complete the LS-262 form for claiming death benefits under the Longshore and Harbor Workers’ Compensation Act and related acts, you’ll need to gather some information:
  1. Name of deceased employee: Enter the first name, middle initial, and last name of the deceased employee.
  2. Last address of the deceased: Provide the full address, including street, city, state, and ZIP code.
  3. Name and address of employer: Enter the name and full address of the employer at the time of the employee’s death.
  4. Name and address of the undertaker: Provide the full name and address of the undertaker responsible for the funeral services.
  5. Amount of undertaker’s bill: State the total bill amount from the undertaker for the funeral services.
  6. Amount Paid: Indicate how much has been paid towards the undertaker’s bill and by whom.
  7. Name of person paying undertaker’s bill: Identify who paid the undertaker’s bill.
  8. Place of Death: Specify the exact location where the death occurred, including city, state, and country.
  9. Date of Death: Enter the date when the employee passed away.
  10. Exact place where the accident occurred: Describe the specific location of the accident leading to death, including any relevant details like name of the vessel or worksite. (For Longshore also include: name of vessel, pier, terminal, etc.) (For DBA also include: name of the DOD facility or associated worksite – i.e. base, FOB, camp, etc.)
  11. Date of Injury: Provide the date when the injury occurred that resulted in death.
  12. Nature of injury or occupational illness and cause of death: Describe the type of injury or illness and how it led to death, including affected body parts.
  13. Name and address of last attending physician (or hospital): Provide details of the physician or hospital that last attended to the deceased.
  14. Widow or Widower:
    • Full name: Enter the full name of the surviving spouse.
    • Address: Provide the complete address of the widow or widower.
    • Social Security Number: Must be filled as required by law.
    • Date of birth: Enter the birthdate of the surviving spouse.
    • Date married to deceased: Specify when the marriage to the deceased took place.
    • Place of marriage: Indicate the city, state, and country of the marriage.
  15. Children of the deceased:
    • Full name: Enter the full names of all dependent children.
    • Address: List the current addresses for each child.
    • Social Security Number: Required for each child.
    • Date of birth: Provide birth dates for all children listed.
  16. All other persons partially or wholly dependent on deceased:
    • Full name: List the names of all other dependents.
    • Income for one year preceding: State the income from various sources before the death.
    • Relationship: Describe the relationship to the deceased.
    • Age: Provide the ages of all dependents.
    • Dependent Amount (Wholly/Partially): Indicate the amount of dependency, whether wholly or partially
Additional instructions and privacy notices on the form guide the completion process, including where to submit the form and legal implications of providing false information. Ensure all details are accurate and complete to facilitate the processing of the claim. It is important to look at the details on the form itself to determine:
  • Who is eligible for a Death Benefit?
  • What terminates widow’s or widower’s benefits?
  • What evidence is needed to support a claim?
  • Time requirement of filing claim?

Contact an Experienced Longshore Worker’s Compensation Death Benefits Lawyer Near You

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The personal injury lawyers near you at Lavis Law Firm handle workers compensation death benefits.
If you need help or have any questions about your job injury, call me at 866-289-2802, or submit your inquiry online Please be advised that you may be facing important legal deadlines so don’t delay.
For any questions that you may have, contact a Longshore Workers Compensation Death Benefits Lawyer.

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