LS-262 proposed Claim for Death Benefits

U.S. Department of Labor

Claim for Death Benefits

Employment Standards Administration
Office of Workers' Compensation Programs

www.dol.gov/esa/owcp/dlhwc/index.htm
Carrier's Number
OBM No.
1215-0160

1. Name of deceased employee (First, Middle Initial, Last)

OWCP Number

a. Social Security Number of deceased (Required by Law)
2. Last address of deceased (Number, Street, City, State, ZIP)

8. Place of Death

9. Date of Death

3. Name and address of employer (Number, Street, City, State, ZIP)

10. Place where injury occurred

11. Date of Injury

12. Nature of injury or occupational illness and cause of death
4. Name and address of undertaker

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. Name of widow/widower (see page 2 for conditions of eligibility)
a. Full Name

b. Address

e. Citizenship

f. Date married to deceased

c. Social Security Number of widow/ widower
(Required by Law)

d. Date of birth

g. Place of marriage (City, State, Country)

15. Children of deceased (see page 2 for qualification)
a. Full name

b. Address

c. Social Security Number

d. Date of birth

e. Citizenship

(Required by Law)

16. Signature of widow/ widower/ guardian

Telephone No.:

17. All other persons partially or wholly dependent on deceased for support (see page 2 for instructions)
b. Income for one year preceding

a. Full name and address

c. Relationship

d. Age

e. Dependent

death
Source

Signature

Amount

Date (mm/dd/yyyy)

Wholly

Partially

[ ]

[ ]

[ ]

[ ]

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.
This Form Replaces Form LS-263 Which is Obsolete

Form LS-262
Rev. April 2009

Instructions:
1. Use this form to claim death benefits under the Longshore and Harbor
Workers’ Compensation Act, Defense Base Act, Outer Continental Shelf
Lands Act, or Nonappropriated Fund Instrumentalities Act. The information
provided will be used to determine entitlement to benefits.
2. Submit claim to a Longshore district office of the Office of Workers’
Compensation Programs (OWCP/ DLHWC).
3. Individual claims must be filed by or in behalf of each person eligible for
benefits [33 U.S.C. 913(a)]. (included are grandchildren, brothers and
sisters, under 18 years, parents, step-parents, parents by adoption,

parent-in-laws, and any person who for more than one year prior to the
employee’s death stood in place of a parent to him/her).
4. Under item 17b, state all sources of income for the year preceding
death by source (Social Security pension, bonds, etc.) and amount. List
separately support deceased furnished you, including the value of any
shelter, food, clothing, or other supplies. Use space below or additional
sheets if needed.
5. Persons are not required to respond to this collection of information
unless it displays a currently valid OMB number.

Conditions of Eligibility
Coverage for Death Benefit

What terminates widow’s or widower’s benefits?

A death benefit is payable under the Longshore Act, or related law, if a
covered employee dies as a result of work-related injury or occupational
disease.

1. Death

Who is eligible for a Death Benefit?

What evidence is needed to support a claim?

2. Remarriage, in which case the widow or widower received a lump sum
payment of two year’s compensation.

1. The deceased worker’s widow or widower living with or dependent for
1. Certified copy of the death certificate of the deceased worker.
support at the time of death; or widow or widower living apart for good cause 2. Widow or widower. Proof of marriage to deceased worker. If either
or because of desertion by worker.
party was married before, proof that earlier marriage was legally ended. A
certified copy of the final divorce decree, or proof or death of a previous
2. Unmarried child (ren) under 18, or if over 18: (a) was (were) wholly
marriage partner may be required before benefits are paid.
dependent on deceased worker and unable to support self (ves) because of
mental or physical disability, or (b) student(s) up to age 23 (must meet certain
3. Children – Certified copy of birth certificate or Order of Adoption. If a
requirements). Includes a posthumous child, legally adopted child, child to
legal guardian has been appointed, a certified copy of the Letters of
whom deceased acted as parent for one year before injury, stepchild, or
Guardianship.
acknowledged illegitimate child.
Time requirement of filing claim
3. If the combined amount due a surviving widow or widower and child or
children is not greater than two-thirds (66 and 2/3 percent) of the worker’s
average weekly wages subject to a maximum benefit of 200 percent of the
national average weekly wage, a benefit is payable for any one of the
following: Grandchildren, brothers or sisters (if dependent at the time of
injury), parents, grandparents, or others satisfying legal requirement of a
dependency. (Consult the Office of Workers’ Compensation Programs for
more information).

Within one year of employee’s death. The time may not begin to run,
however, until the person claiming the benefit would reasonably have
related the employee’s death to his or her employment. In case of death
due to an occupational disease, a claim may be filed within two years after
the claimant becomes aware, or in the exercise of reasonable diligence or
by reason of medical advice should have been aware, of the relationship
between the employment, the disease 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
(1) The Longshore and Harbor Workers' Compensation Act (LHWCA), 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 information on claimants and their immediate families. (2) Information which the Office has will be used to
determine eligibility for the amount of benefits 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 the 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 and have been paid properly, and, where appropriate, to pursue salary/administrative offset and debt collection
actions required or permitted by law. (7) 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
The following statement is made in accordance with the Privacy Act of 1974 (5USC 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the
following information is 33.U.S.C. 913 (a). Use of this form is optional, however furnishing the information is required in order to obtain and/or retain benefits. According to the Paperwork
Reduction Act of 1995, an agency may not conduct or sponsor and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 1215-0160. The time required to complete this information collection is estimated to average 2 minutes per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any aspect of this collection of information, including suggestions for the reducing this burden, to the U.S. Department of Labor, Division of
Longshore and Harbor Workers’ Compensation, Room C-4315, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.