Home Claims Form B Death Benefit Claim Form

Form B Death Benefit Claim Form

Form B Death Benefit Claim Form

 

INSTRUCTIONS: ALABAMA DEATH BENEFIT CLAIM FORM (Form B)

 

 

As part of the death benefit claim process for survivors of Alabama peace officer or fireman who have had their claim denied, a form B will be filed. This document can be obtained from the website maintained by the Alabama Board of Adjustment.

 

Alabama Death Benefit Claim Form B Step 1: Enter your name on the first blank line.

 

Alabama Death Benefit Claim Form B Step 2: On the first three blank lines of line 1, enter your name, mailing address and zip code.

 

Alabama Death Benefit Claim Form B Step 3: On the next blank line of line 1, enter your home telephone number, including the area code.

 

Alabama Death Benefit Claim Form B Step 4: On the next blank line of line 1, enter your work telephone number, including the area code.

 

Alabama Death Benefit Claim Form B Step 5: On line 2, enter the date of death of the peace officer or fireman.

 

Alabama Death Benefit Claim Form B Step 6: On line 3, enter how long the peace officer or fireman had been employed in that capacity.

 

Alabama Death Benefit Claim Form B Step 7: Line 4 states that you must attach a death certificate and affidavit from the head of the agency which employed the deceased stating the status of their employment and the circumstances of their death.

 

Alabama Death Benefit Claim Form B Step 8: In section 5, you must document all surviving dependents in the table provided. In the first column, enter the full name and address of each dependent.

 

Alabama Death Benefit Claim Form B Step 9: In the second column, enter each dependent's relationship to the deceased.

 

Alabama Death Benefit Claim Form B Step 10: In the third column, enter each dependent's age.

 

Alabama Death Benefit Claim Form B Step 11: In the fourth column, indicate whether the deceased was contributing to support each listed dependent.

 

Alabama Death Benefit Claim Form B Step 12: On line 6, enter the geographic location of the injury or death.

 

Alabama Death Benefit Claim Form B Step 13: On line 7, state in your own words the circumstances related to the death of the peace officer or fireman.

 

Alabama Death Benefit Claim Form B Step 14: Sign the form where indicated, then have it certified by a notary public.

 

Download the PDF file .

Comments

comments