Death Claim Allowed Order
· Displayed for language and information only – not format. Spacing is modified to allow for descriptive information in the right border.
· Most orders will be two pages.
· Order will be printed on most current BWC letterhead and will include BWC Order header, footer and watermark.
· Information appearing in bold, black text is standard language that will appear on all orders.
· Information in regular black text is found in an insert. Inserts can be automatically inserted by the system under specified conditions, user selected, and/or can contain variable text pulled from the system or entered by the user.
· Information contained in double angle brackets (< >) is information automatically inserted by the system or is entered by the user in the specified add text field.
· Inserts, when selected, will appear in the order listed.
Correspondence language
/Comments
Order header and addressee information
Selected dependent name> <Date>Dependent Street Name> Date mailed
Dependent City, State, Zip> / The CSS will choose the dependent to which the order will be addressed. Date mailed will be the system batch date plus one day, which should always be equal to the date the correspondence is delivered to the pre-sort house.
Injured worker: <IW name> Employer name: <Emp. name>
Claim number: <Claim #> Policy number: <Risk #>
Injury date: <DOI> Manual number : <Manual no.>
Claim type: <Accident, OD, Death>
/ Standard header for all V3 correspondence.Death initial allowance inserts
A request for determination of death benefits has been received in relationship to the following accident/occupational disease:<5 lines of add text> / User will enter brief description of injury or disease that led to IW’s death. For claims that are being allowed for the first time, this should also include a description of the accident that led to the IW’s death.
The Ohio Bureau of Workers’ Compensation (BWC) has made the following decision: The injured worker’s death was related to an industrial accident or occupational disease, therefore the claim is being ALLOWED as a death claim. This decision is based on:
<5 lines of add text> / User enters reason for allowing death benefits.
Medical benefits will be paid in accordance with the Ohio Bureau of Workers’ Compensation (BWC) rules and guidelines. / This insert is automatically included when the claim is in allow/appeal status.
Wages and total death benefit insert
The full weekly wage (FWW) is set at <FWW>. Accrued compensation will be based on this rate according to BWC rules and guidelines. / This insert is used when FWW is being set for accrued compensation.The full weekly wage for this claim is set at the minimum amount allowed based on the statewide average weekly wage for the date of injury because requested wage information has not been provided. / The user selects this insert when FWW is set at the minimum.
The average weekly wage (AWW) is set at <AWW>. Accrued compensation will be based on this rate according to BWC rules and guidelines. / This insert is used when the AWW is being set. The wage and rate will be pulled from the system.
BWC may reconsider the full and/or average weekly wage upon submission of additional information. / This insert appears whenever either the FWW or AWW insert is included.
Apportionment inserts (allowed only)
The benefits will be apportioned as follows:<Surviving Spouse Name>, date of birth <date of birth>, is awarded $<amount> per week as the surviving spouse to begin <Begin date>. Payment is to continue unless future facts and circumstances warrant stopping payment in accordance with the statute. In the event of remarriage, the surviving spouse is hereby ordered to immediately notify BWC. At that time, a new order will be issued for payment of a lump-sum award to the surviving spouse as provided by statute. / There must be at least one apportionment insert selected when the AWW insert is present. User can select inserts for surviving spouse, child under the age of 18, child over the age of 18, and/or incapacitated child in whatever combination needed.
The variable information will be pulled from the death benefit plan for the surviving spouse.
<Surviving Child under age 18 Name>, date of birth <DOB>, is awarded $<amount> per week as a dependent child to begin <begin date>, paid in care of <paid to>. Payment will continue until <18th birthday>, when the child reaches the age of 18. Once the child reaches age 18, upon submission of proof of full-time enrollment from an accredited educational institution, payment will continue and be paid directly to the child until the enrollment is discontinued or the child reaches the age of 25. / The system will complete the variable information based on information in the death benefit plan for dependent children. A new order must be issued when a dependent child reaches age 18.
This insert will be selected by the system for each dependent who is under age 18, has an active plan, and who is not physically or mentally incapacitated.
<Surviving Child over age 18 Name>, date of birth <DOB>, is awarded $<amount> per week as a dependent child to begin <begin date>. Payment will continue upon submission of proof of ongoing full-time enrollment from an accredited educational institution, until the enrollment is discontinued or until <date child is age 25>, the date when the child will reach the age of 25. The child is hereby ordered to immediately notify BWC of changes in enrollment status. / The system will complete the variable information based on information in the death benefit plan for dependent children.
A new order must be issued when the child stops attending school or reaches age 25.
This insert will be selected by the system for each dependent who is over age 18, has an active plan and who is not physically or mentally incapacitated.
<Physically or mentally incapacitated child name>, date of birth <DOB>, is awarded $<amount> per week as a physically or mentally incapacitated dependent child to begin <begin date>. Payment will be made to <payee name> and will continue until evidence is received of new and changed circumstances. / The system will complete the variable information based on information in the death benefit plan for dependent children with the physically or mentally incapacitated flag set.
If there is a guardian for the child, the guardian’s name will be listed as the payee. If there is no guardian for the child, the child’s name will be inserted as the payee.
<Dependent name>, date of birth <DOB>, has been found to be wholly dependent and is awarded $<amount> per week as to begin <begin date>. Payment will continue based on proof of continued eligibility. / The system will complete the variable information based on information in the death benefit plan for dependents flagged as wholly dependent and with a role of parent or other.
<Dependent name>, date of birth <DOB>, has been found to be partially dependent and is awarded $<amount> per week as to begin <begin date>. Payment will continue based on proof of continued eligibility. / The system will complete the variable information based on information in the death benefit plan for dependents flagged as partially dependent and with a role of parent or parent or other.
An award of $<amount> is granted to <prospective dependent> who has been found to be prospectively dependent. / Allow for three prospective dependents inserts. User enters amount and prospective dependent name.
Reapportionment inserts (subsequent death decisions)
The Ohio Bureau of Workers’ Compensation (BWC) has made the following decision:Widowed Claimant Remarried:
BWC finds from proof on file that the widowed claimant, <name> remarried on <date>. It is therefore ordered that the widowed claimant be granted a final award of a death benefit, in accordance with Ohio Revised Code 4123.59.
Compensation is payable in one lump sum, consisting of two years of compensation from <begin date> to <end date> at the weekly rate of <rate> for a total award of $< amount>.
The lump sum will be reduced by $< total > due to <5 lines add text>.
Dependent Child Age 18/Not Enrolled in School:
BWC finds that the dependent child, <name>, has reached the age of 18 and is no longer enrolled in an accredited educational institution and is, therefore, no longer eligible to receive benefits, effective <date>.
Dependent Child Age 25:
BWC finds that the dependent child, <name>, has reached the age of 25 and is, therefore, no longer eligible to receive benefits, effective <date>, the child’s twenty-fifth birthday.
Other:
<five lines of variable text> / These inserts are used when benefits to a dependent are ending. User will then select either the insert stating that there are no remaining eligible dependents or insert(s) regarding reapportionment. User enters all variable data.
This paragraph is not required and should only be included when an amount to reduce the payment by is entered by the user. Reasons that the lump sum could be reduced include compensation paid after the date of marriage, a previously granted LSA, or an existing overpayment.
Benefits are no longer payable as there is no remaining eligible dependent. / This insert is used when benefits are stopped for the last remaining dependent and no compensation will be paid.
The benefits will be reapportioned as follows:
<Surviving Spouse Name>, date of birth <date of birth>, is awarded $<amount> per week as the surviving spouse to begin <Begin date>. Payment is to continue unless future facts and circumstances warrant the stopping of payment in accordance with the statute. In the event of remarriage, the surviving spouse is hereby ordered to immediately notify BWC. At that time, a new order will be issued for payment of a lump-sum award to the surviving spouse as provided by statute. / There must be at least one apportionment insert selected when the AWW insert is present. User can select inserts for surviving spouse, child under the age of 18, child over the age of 18, and/or incapacitated child in whatever combination needed.
The variable information will be pulled from the death benefit plan for the surviving spouse.
If a LSA has been granted, the information regarding the reduced rate must be described using add text.
<Surviving Child under age 18 Name>, date of birth <DOB>, is awarded $<amount> per week as a dependent child to begin <begin date>, paid in care of <paid to>. Payment will continue until <18th birday>, when the child reaches the age of 18. Once the child reaches age 18, upon submission of proof of full-time enrollment from an accredited educational institution, payment will continue and be paid directly to the child until the enrollment is discontinued or the child reaches the age of 25. / The system will complete the variable information based on information in the death benefit plan for dependent children. A new order must be issued when a dependent child reaches age 18.
This insert will be selected by the system for each dependent who is under age 18, has an active plan, and who is not physically or mentally incapacitated.
<Surviving Child over age 18 Name>, date of birth <DOB>, is awarded $<amount> per week as a dependent child to begin <begin date>. Payment will continue upon submission of proof of ongoing full-time enrollment from an accredited educational institution, until the enrollment is discontinued or until <25th birthdate>, the date the child will reach the age of 25. The child is hereby ordered to immediately notify BWC of changes in enrollment status. / The system will complete the variable information based on information in the death benefit plan for dependent children.
A new order must be issued when the child stops attending school or reaches age 25.
This insert will be selected by the system for each dependent who is over age 18, has an active plan and who is not physically or mentally incapacitated.
<Physically or mentally incapacitated child name>, date of birth <DOB>, is awarded $<amount> per week as a physically or mentally incapacitated dependent child to begin <begin date>. Payment will be made to <payee name> and will continue until evidence is received of new and changed circumstances. / The system will complete the variable information based on information in the death benefit plan for dependent children with the physically or mentally incapacitated flag set.
If there is a guardian for the child, the guardian’s name will be listed as the payee. If there is no guardian for the child, the child’s name will be inserted as the payee.
<Dependent name>, date of birth <DOB>, has been found to be wholly dependent and is awarded $<amount> per week as to begin <begin date>. Payment will continue based on proof of continued eligibility. / The system will complete the variable information based on information in the death benefit plan for dependents flagged as wholly dependent and with a role of parent or other.
<Dependent name>, date of birth <DOB>, has been found to be partially dependent and is awarded $<amount> per week as to begin <begin date>. Payment will continue based on proof of continued eligibility. / The system will complete the variable information based on information in the death benefit plan for dependents flagged as partially dependent and with a role of parent or parent or other.
Funeral expenses insert (allowed only)