Claim for Death Benefits

Claim for Death Benefits                                                              U.S. Department of Labor
            Print       Reset                                                         Office of Workers' Compensation Programs

1. Name of deceased employee (First, Middle Initial, Last)               OWCP Number                      Carrier's Number                 OMB No. 1240-0014
                                                                                                                                           Expires: 11/30/2026
a. Social Security Number (Required by Law)
                                                                         8. Place of Death                                                9. Date of Death
2. Last address of last deceased (number, street, city, state, ZIP,
    country)


                                         United States
                                                                         10. Exact place where accident occurred (Street address, 11. Date of Injury
3. Name and address of employer (number, street, city, state, ZIP)       city, town, country) (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.)


3a. Injury is reported under the: Defense Base Act                                                                                       United States
4. Name and address of undertaker                                        12. Nature of injury or occupational Illness and cause of death (Give parts
                                                                             of body affected if Injured)



5. Amount of undertaker's bill          6. Amount Paid                   13. Name and address of last attending physician (or hospital)


7. Name of person paying undertaker's bill

14. Widow or Widower
a. Full name and address                                                 b. Social Security Number      c. Date of birth            d. Nationality



                                     United States                                            Telephone Number
e. Date married to deceased      f. Place of marriage (City, State, Country)   g. Signature of widow, widower, and/or                       Date
                                                                                 guardian of children
                                  United States
15. Children of deceased (see page 2 for qualification)
a. Full name                              b. Address                                         c. Social Security Number d. Date of birth      e. Nationality
                                                                                                 (Required by Law)




16. All other persons partially or wholly dependent on deceased          b. income for one year preceding     c. Relationship   d. Age        e. Dependent
   support (See page 2 for instructions)                                    death
                                                                            Source               Amount                                     Wholly Partially
a. Full name and address




Signature                                            Date (mm/dd/yyyy)
Guardian?
f. Full name and address




Signature                                            Date (mm/dd/yyyy)
Guardian?
Important Notice
Section 31 (a)(1) of the Longshore Act, 33 U.S.C. 931 (a)(1), provides, as follows: Any claimant or representative of a claimant who knowingly and
willfully makes a false statement or representation for the purpose of obtaining a benefit or payment under this Act shall be guilty of a felony,
and on conviction thereof shall be punished by a fine not to exceed $10,000, by imprisonment not to exceed five years, or by both.
                                                                                                                                             Form LS-262
                                                                                                                                             Rev. Nov 2023
Instructions:
1. Use this form to claim death benefits under the Longshore andHarbor          3. individual claims must be filed by or in behalf of each personeligible for
Workers' Compensation Act, Defense Base Act, Outer Con-tinental                 benefits [33 U.S.C. 913(a)]. (included are grandchildren,brothers and sisters
Shelf Lands Act, or Nonappropriated Fund InstrumentalitiesAct. The              under 18 years, parents, step-parents, parentsby adoption, parents-in-law, and
information provided will be used to determineentitlement to benefits.          any person who for more thanone year prior to the employee's death stood in
                                                                                place of a parentto them.)
2. Please submit electronically through the DFELHWC’s Secure
Electronic Access Portal (SEAPortal) (preferred method) https://                4. Under item 16(b), state all your income for the year precedingdeath by source
seaportal.dol.gov/portal/                                                       (Social Security pension, bonds, etc.) and amount.List separately support
or to the Case Create Fax Number (202) 513-6814. Alternatively,                 deceased furnished you, including the value ofany shelter, food, clothing, or other
submit the claim by mail to the Central Mail Receipt site at:                   supplies. Use space below oradditional sheets if needed.
U.S. Department of Labor Office of Workers’ Compensation Programs
Division of Federal Employees’, Longshore and Harbor Workers'                   5. A person other than the claimant may complete claim for thebeneficiary.
Compensation 400 West Bay Street, Suite 63A, Box 28 Jacksonville, FL
32202                                                                           6. Persons are not required to respond to this collection of informationunless it
(Please be sure to include your case number.)                                   displays a currently valid OMB number.
Conditions of Eligibility                                                             What terminates widow's or widower's benefits?

Coverage for Death Benefit                                                            1. Death

A death benefit is payable under the Longshore Act, or related law, if                2. Remarriage, in which case the widow or widower receives a lump
a covered employee dies as a result of work-related injury or                         sum payment of two year's compensation.
occupational disease.
                                                                                      What evidence is needed to support a claim?
Who is eligible for a Death Benefit?
                                                                                      1. Widow or widower. Proof of marriage to deceased worker. If
1. The deceased worker's widow or widower living with or dependent                    either party was married before, proof that earlier marriage was
for support at the time of death; or widow or widower living apart for                legally ended. A certified copy of the final divorce decree, or proof of
good cause or because of desertion by worker.                                         death of a previous marriage partner may be required before benefits
                                                                                      are paid. Certified copy of the death certificate of the deceased
2. Unmarried child(ren) under age 18, or if over 18: (a) was (were)                   worker.
wholly dependent on deceased worker and unable to support
self(ves) because of mental or physical disability, or (b) student(s) up              2. Children - Certified copy of birth certificate or Order of Adoption. If
to age 23 (must meet certain requirements). Includes a posthumous                     a legal guardian has been appointed, a certified copy of the Letters of
child, legally adopted child, child to whom deceased acted as parent                  Guardianship.
for one year before injury, stepchild, or acknowledged illegitimate
child.
                                                                                      Time requirement of filing claim
3. If the combined amount due a surviving widow or widower and                        Within one year of employee's death. The time may not begin to run,
child or children is not greater than two-thirds (66 and 2/3 percent) of              however, until the person claiming the benefit would reasonably have
the worker's average weekly wages subject to a maximum benefit of                     related the employee's death to his or her employment. In case of
200 percent of the national average weekly wage, a benefit is                         death due to an occupational disease, a claim may be filed within two
payable for any one of the following: Grandchildren, brothers or                      years after the claimant becomes aware, or in the exercise of
sisters (if dependent at time of injury), parents, grandparents, or others            reasonable diligence or by reason of medical advice should have
satisfying legal requirements of dependency. (Consult the Office of                   been aware, of the relationship between the employment, the disease
Workers' Compensation Programs for more information.)                                 and the death.
Use the space below or a separate sheet of paper to continue answers. Please number each answer to correspond to the number
of the item being continued.




                                                                  Privacy Act Notice
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a) you are hereby notified that (1) the Longshore and Harbor Workers' Compensation Act,
as amended and extended (33 U.S.C. 901 et seq.) (LHWCA) is administered by the Office of Workers' Compensation Programs of the U.S. Department of Labor,
which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to determine
eligibility for and the amount of benefits payable under the LHWCA. (3) Information may be given to the employer which employed the claimant at the time of
injury, or to the insurance carrier or other entity which secured the employer's compensation liability. (4) Information may be given to physicians and other
medical service providers for use in providing treatment or medical/vocational rehabilitation, making evaluations and for other purposes relating to the medical
management of the claim. (5) Information may be given to the Department of Labor's Office of Administrative Law Judges (OALJ), or other person, board or
organization, which is authorized or required to render decisions with respect to the claim or other matter arising in connection with the claim. (6) Information may
be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the LHWCA, to determine whether
benefits are being or have been paid properly, and, where appropriate, to persue salary/administrative offset and debt collection actions required or permitted by
law. Disclosure of the claimant's Social Security Number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN and other
information maintained by the Office may be used for identification, and for other purposes authorized by law. (8) Failure to disclose all requested information may
delay the processing of the claim, the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.
Note: The notice applies to all forms requesting information that you might receive from the Office in connection with the processing and/or
adjudication of the claim you filed under the LHWCA and related statutes.

                                                              Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid
OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes/hours per response, including time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
The obligation to respond to this collection is “required to obtain or retain benefits” . Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers' Compensation Programs, 200
Constitution Avenue, N.W., Room S-3524, Washington, DC 20210. Note: Please do not return the completed form to this address.
                                               DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
                                                                                                                                                      Form LS-262
                                                                                                                                                      Rev. Nov 2023
                                                                                                                                                      Page 2