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Office of Workers' Compensation Programs

Division of Longshore and Harbor Workers' Compensation (DLHWC)

CHAPTER 2-202 — DEATH

  1. Purpose and Scope. This Chapter contains the procedures for the initial review of a death case file by the Claims Examiner (CE) or Claims Examiner Clerk (CEC). This Chapter also augments the information contained in PM-201. Information on the processing of secondary death cases may be found in PM 3-302.
  2. Policy. The Claims Examiner (CE), assisted by the Claims Examiner Clerk (CEC), is responsible for processing death claims and insuring that the survivor(s) of the deceased employee receives all benefits to which they may be entitled to under the Act, while protecting the rights of all parties. Claims must be in writing and filed by or for the individual claiming benefits with the DD of the compensation district in which the injury or death occurred.
  3. Contents of Death Case. At a minimum, a death case should contain the following:
    1. Report of Injury/Death. For example, Form LS-201 or LS-202 (Exhibits 15, and 16, PM 10-200).
    2. Death Certificate. The case should also include a death certificate, and evidence concerning the factors of employment or injury suspected to be the cause of, to have contributed to, or to have hastened death.
    3. Certificates for Dependents. These should include a

      marriage certificate, birth certificates for the eligible dependents, as well as evidence to establish student status and dependency where appropriate.

    4. SSN of each beneficiary.
    5. Claim for Benefits. One or all of the following claim forms should be included:
      1. Claim for Death Benefits, Form LS-262, Exhibit 32, PM 10-200;
      2. Application for Continuation of Death Benefit for Student, Form LS-266, Exhibit 34, PM 10-200;
      3. Certificate of Funeral Expenses, Form LS-265, Exhibit 33, PM 10-200.
  4. Processing of Death Cases. If the names and/or addresses of beneficiaries are unknown, the CE should write to the EC requesting the information along with wage information and evidence of voluntary payment of compensation (if the case has not been controverted). Upon receipt of this information the CE should write to the widow/widower and/or beneficiaries enclosing blank Forms LS-262, Claim for Death Benefits (See Exhibit 32, PM 10-200) and LS-265, Certification of Burial Expenses (See Exhibit 33, PM 10-200). The CE should also request copies of the death certificate, marriage certificate and any other pertinent information which may be missing SSN. A copy of this letter should be sent to the EC.