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Death Benefit Claim Form

Death Benefit Claim Form

 

INSTRUCTIONS: ALABAMA DEATH BENEFIT CLAIM FORM (Form B)

 

 

When an Alabama peace officer or fireman dies, their survivors may seek death benefits from the state by filing a form B death benefit claim form. This document can be obtained from the website of the Alabama Department of Finance. You must print or type all of your answers in ink.

 

Alabama Death Benefit Claim Form B Step 1: Enter your name on the line above the words "Name of Claimant."

 

Alabama Death Benefit Claim Form B Step 2: On line 1, enter your name and mailing address, as well as your home and business telephone numbers.

 

Alabama Death Benefit Claim Form B Step 3: On line 2, give the date of death of the fireman or police officer.

 

Alabama Death Benefit Claim Form B Step 4: On line 3, give the duration of the deceased's employment in that capacity.

 

Alabama Death Benefit Claim Form B Step 5: Line 4 states that you must attach a death certificate as documentation for your claim. You must also include an affidavit from the head of the agency which employed the deceased which states their employment status and provides a description of the circumstances leading to their death.

 

Alabama Death Benefit Claim Form B Step 6: Line 5 requires you to enter all surviving dependents, including spouses, children from a current or previous marriage and parents. Attach additional sheets as necessary. Give the full name and address of every dependent, as well as their relationship to the deceased and their age. Note whether they were receiving support from the deceased.

 

Alabama Death Benefit Claim Form B Step 7: On line 6, give the geographic location of the site of injury or death.

 

Alabama Death Benefit Claim Form B Step 8: On line 7, provide your explanation of the circumstances of death, including the name of the deceased. Attach additional sheets as necessary.

 

Alabama Death Benefit Claim Form B Step 9: If you are represented by an attorney, enter their name, address and telephone number.

 

Alabama Death Benefit Claim Form B Step 10: Sign the form in the presence of a notary public.

 

Alabama Death Benefit Claim Form B Step 11: File the form in duplicate along with all supporting documentary evidence. This must also be submitted in duplicate. 

 

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