Employee Death Notice Pdf Format - Free Download
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EMPLOYER’S NOTICE OF DEATH
Employer
Address of Employer
Employee Date of Birth
Social Security No.
Married Yes No
Sex Male Female
Occupation Status
(if leave of absence, retired or terminated, please give date) Active Leave of
Absence Retired Terminated Date: Date Employed Date Employee insured with
Employer Basic Optional If ever terminated & reinstated indicate new effective date:
Basic Optional Employer last contributed to premium for month of:
Employee last contributed to premium for month of: Date of Death If death was due
to an accident, was Employee working at the time of the accident Yes No Date of
Accident If death was due to an accident, please state how and where it occurred
Name of Beneficiary Relationship to Deceased Date last worked Reason for leaving
Amount of regular earnings for Employee at date of death
Annual $ Weekly $ Date of last change of earnings Class Effective Date for current
insurance Amount of Basic Insurance Life Accidental Death Amount of Optional
Insurance Life Accidental Death To Be Completed Only If Claim Is Being Made
Under Dependent Coverage Dependent (Deceased) Date of Birth Social Security No.
Relationship to Employee Address If claim for spouse, was he/she divorced or legally
separated from the Employee Yes No If claim for a child, indicate if single or
married Was dependent employed Yes No If Yes Full-time or Part-time If yes,
please indicate the name and address of Employer If child was a college student,
please indicate if full-time or part-time student and the name and address of the
college Date Dependent insured with Employer Basic Optional If ever terminated &
source: lsufirst.org
