Form LS-262 – Claim for Death Benefits

Jurisdiction: Country: United States | Province or State: Federal

What is a Form LS-262 – Claim for Death Benefits?

Form LS-262 is the federal claim form you use to request death benefits after a covered worker dies due to a work-related injury or occupational disease. The form is administered by the U.S. Department of Labor’s Office of Workers’ Compensation Programs. It supports claims under the Longshore and Harbor Workers’ Compensation Act and its extensions. Those laws cover maritime and certain related employment, as well as specific federal extensions to overseas and offshore work.

You use this form to tell the government, the employer, and the insurance carrier that a work-related death occurred and that you, as a dependent, are claiming benefits. It collects the facts needed to establish coverage, identify eligible survivors, and calculate the benefit amount. It also provides a formal record to start the review and payment process.

Who typically uses this form?

Surviving spouses, dependent children, legal guardians of minor children, dependent parents, and sometimes other dependent family members. Estate representatives can also initiate the claim to secure funeral expenses or help identify eligible dependents. If the worker died after a prior work injury claim, survivors file Form LS-262 as a separate claim focused on death benefits.

You might need this form if any of the following apply:

• A longshore worker suffered a fatal accident on a pier, terminal, or dry dock.
• A shipbuilder or ship repairer died due to an occupational disease, such as mesothelioma.
• An employee working on the outer continental shelf died in a platform incident.
• A covered overseas contractor died from a job-related event or disease.
• A retired worker later died from a longstanding job-caused disease that meets coverage rules.

Typical usage scenarios include a fatal fall at a marine terminal, a fatal crush injury in a shipyard, a contractor’s death following a hostile incident while working overseas, or a death from cumulative exposures like asbestos or hazardous chemicals. In each case, Form LS-262 is the official way you assert eligibility and ask for benefits for yourself and other dependents.

The benefits you claim may include weekly compensation based on the deceased worker’s average weekly wage, funeral expenses up to a statutory limit, and ongoing payments for eligible dependents. The exact amounts depend on family status, wage history, and legal caps. The insurer or self-insured employer pays approved benefits. The Department of Labor oversees the claim and resolves disputes.

Form LS-262 is structured to capture the essentials: who died, who is claiming, what happened, when it happened, where it occurred, who employed the worker, what the worker earned, and who depends on the deceased for support. It also provides a place for your signature certifying the truth of your statements, which is a key part of processing and enforcement.

When Would You Use a Form LS-262 – Claim for Death Benefits?

You use Form LS-262 when a worker’s death is linked to covered employment. The timing and facts matter. If the death followed a traumatic workplace incident, you file once you have basic details, such as the death certificate and the employer’s identity. If the death resulted from an occupational disease, you file when you first learn the death was related to the job exposure. In both cases, you should not wait for every last document before filing. Filing starts the claim clock and protects your rights, while you can send more evidence later.

Here are practical examples to show when you file:

• A crane operator at a shipyard suffers a fatal injury during cargo operations. You are the surviving spouse with two minor children. You file Form LS-262 to claim weekly death benefits for yourself and the children, along with funeral expenses.
• A welder who retired years ago dies from lung disease that a doctor connects to ship repair work. You learn from the medical report that the disease was job-related. You file Form LS-262 and include the medical opinion and exposure history.
• A contractor working overseas under a federal extension dies in a vehicle incident while performing job duties. The family files Form LS-262 listing the overseas employer and attaches the official incident report as available.
• No spouse or children survive. The worker’s dependent mother relied on the worker for support. She files Form LS-262 with proof of dependency and seeks death benefits as the next eligible dependent.
• A worker passes away after an accepted work injury that never fully resolved. The injury is a cause of death. The executor files Form LS-262 to request funeral expenses, and the surviving spouse files the same claim form listing all dependents for weekly benefits.

Typical filers include surviving spouses, legal guardians for children, dependent parents, and estate representatives. Employers and insurers do not file this form for you. They may assist, but you are responsible for making the claim. If more than one dependent plans to claim benefits, one complete Form LS-262 can identify all dependents; however, adult dependents often file their own forms or affidavits to establish their eligibility.

You should file promptly. There are filing deadlines. A claim for death due to a traumatic injury is generally due within one year from the date of death. If the death is due to an occupational disease, the deadline is generally two years from when you became aware that the death was job-related. If any voluntary benefits were paid, the time can run from the last payment. When in doubt, file now and supplement later. Filing preserves your rights and triggers a case number.

Legal Characteristics of the Form LS-262 – Claim for Death Benefits

Form LS-262 is a legally significant claim under federal workers’ compensation law. By signing, you certify that the information is true to the best of your knowledge. False statements can carry penalties. The form initiates a legal process governed by statute and regulation. The Office of Workers’ Compensation Programs receives and manages your claim. The employer or carrier must respond and either accept liability and pay or state reasons for denial. If there is a dispute, you may use the established adjudication process, including formal hearings.

The form is legally binding in the sense that it asserts rights conferred by federal law and seeks enforceable benefits from the responsible employer or insurer. It is not a contract between private parties. Instead, it is a statutory claim that activates duties on the employer/carrier to investigate and, if warranted, pay benefits. The form also creates a record for any later audit or hearing.

Enforceability rests on a few pillars. First, the longshore system is no-fault. You do not need to prove employer negligence. You must show that the death arose out of and in the course of employment and that the worker was covered by the law. There is a presumption that a claim comes within the law once you present basic evidence of an injury or disease and a connection to work. The employer may rebut that presumption. Second, medical evidence is key. A physician’s opinion linking the death to the work incident or exposure supports the claim. Third, timeliness matters. Compliance with the filing deadlines protects your claim. Fourth, proper notice to the employer and the government supports due process.

General legal considerations include dependency and status. Spouses, minor children, certain students up to a defined age, and children incapable of self-support are typical beneficiaries. If there is no spouse or child, dependent parents or siblings may qualify. Death benefits are paid as a percentage of the worker’s average weekly wage, subject to statutory limits and annual adjustments. A portion is set aside for funeral expenses up to a statutory cap. Benefits are paid directly by the employer’s insurance carrier or the self-insured employer. The Department of Labor oversees compliance, resolves disputes, and approves any attorney fees related to successful claims.

If multiple jurisdictions might apply, federal benefits usually take precedence for covered maritime employment and specific federal extensions. You can still file a federal claim even if you pursued or received state benefits. Offsets may apply, and the carrier may coordinate benefits. The safest approach is to file promptly under the federal law that covers the job.

How to Fill Out a Form LS-262 – Claim for Death Benefits

Before you start, gather the essentials. You will need the death certificate, the worker’s full legal name and date of birth, Social Security number if available, the employer’s name and address, the place and date of death, and any medical records or reports that tie the death to the work. If you are a surviving spouse, find your marriage certificate. For children, locate birth certificates and, if over the usual age threshold, proof of full-time school enrollment or documentation of disability. If you seek funeral benefits, collect the funeral home invoice and proof of payment. Keep copies of everything you submit.

Follow these steps:

1) Identify the deceased worker

• Enter the worker’s full name exactly as it appears on official records.
• Provide the worker’s date of birth and date of death.
• Include the Social Security number if you have it. If you do not, leave it blank rather than guess.
• List the worker’s last known address. If the worker was overseas or offshore, use the most recent domestic address available.
• State the occupation at the time of the injury or at retirement if the claim relates to occupational disease.

2) Describe the employer and insurance carrier

• Enter the employer’s full legal name, mailing address, and phone number if known.
• If you know the insurance carrier, list it. If not, provide the employer details and leave the carrier blank. The Department of Labor will identify the carrier during processing.
• If the worker was a contractor under a federal extension, list the contracting employer the worker was actually employed by, not just the government client.

3) Provide incident and causation details

• Describe the injury or exposure that caused the death. Keep it factual and concise. Example: “Crush injury during container lift” or “Asbestos exposure during ship repair leading to mesothelioma.”
• Provide the date and place of the incident or the period of exposure. If the death stems from cumulative exposures, give a range and identify the primary worksites.
• If there was an accident report, summarize the date and location. Do not attach originals you cannot replace; send copies.
• State clearly that the death is related to the work incident or exposure, based on medical evidence if you have it. If you have a doctor’s opinion, mention it and attach it.

4) List all survivors and dependents

• Identify your relationship to the deceased (spouse, child, parent, guardian, other dependent).
• For a spouse, provide your full name, current address, date of marriage, and whether you cohabited until death. If separated, explain briefly and attach any relevant court papers.
• For each child, provide full name, date of birth, and current address. State whether the child is a minor, a full-time student, or incapable of self-support due to disability. Attach birth certificates and school or medical documentation as needed.
• For dependent parents or siblings, describe the dependency. State the amount and frequency of support the worker provided and for how long. Attach any proof, such as bank statements or affidavits.
• If you are a legal guardian, attach letters of guardianship or a court order.

5) Provide wage and employment information

• State the worker’s average weekly wage if known. Use recent pay stubs, a year-end wage statement, or other payroll records. If you are not sure, describe the wage structure (hourly rate, overtime pattern, per diem).
• List the job title and primary duties. This helps confirm coverage under the law.
• Provide dates of employment with the listed employer. If the worker had multiple employers relevant to the exposures, list the most recent or most significant.

6) Claim funeral and burial expenses

• Indicate whether you are seeking funeral expense reimbursement.
• Attach the funeral home invoice and proof of payment. If the bill is unpaid, state who will be responsible for payment.
• The law caps funeral reimbursement at a set amount. Do not inflate the request. Submit the actual bill.

7) Identify any prior claims or case numbers

• If the worker had a prior injury claim under the same system, list the case number if you have it.
• If you have already notified the employer or filed other forms, state that and include dates.

8) Sign and date the claim

• Read the certification carefully. You are declaring that the information is true to the best of your knowledge.
• Sign your full legal name. If you are signing on behalf of a minor or an incapacitated adult, sign your name and state your capacity (for example, “Jane Doe, Guardian of John Doe, minor”).
• Date the claim. Unsigned or undated claims can be rejected or delayed.

9) Attach supporting documents

• Death certificate.
• Marriage certificate, if claiming as a spouse.
• Birth certificates for children and proof of full-time student status or disability when applicable.
• Medical reports linking the death to the injury or exposure.
• Pay records supporting the average weekly wage.
• Funeral invoice and proof of payment.
• Guardianship or dependency documents for non-spouse claimants.
• Keep a complete set of copies for your records.

10) File the claim

• Submit the form to the Department of Labor office that handles these claims. If you are unsure which office applies, file with any office handling these cases and request routing. You can also submit to the employer or the insurer, but you should file with the Department to establish the claim formally.
• Use a trackable method and keep proof of delivery. Note the date you mailed or transmitted the form.

11) Notify the employer and insurer

• Provide a copy to the employer and, if known, the insurance carrier. Keep proof of delivery.
• If you do not know the carrier, the employer must supply that information during processing.

12) After you file, monitor the case

• You should receive a case number. Write it on all future correspondence.
• Respond promptly to requests for more information or documents. Delays can slow payment.
• If the employer or carrier denies the claim, you have a right to request further review and a hearing. Follow the instructions provided in the notice.

Practical tips to avoid delays

• File even if you are awaiting a medical opinion. You can add medical evidence later.
• List every dependent on the claim. Omitted dependents may wait longer for benefits.
• Be consistent in names and dates across all documents. Small discrepancies cause avoidable questions.
• Never send original vital records unless specifically requested. Use certified copies when possible.
• If you move, update your address with the Department of Labor, the employer, and the insurer at once.

How benefits are calculated and paid

• Death benefits are based on a percentage of the worker’s average weekly wage, subject to statutory maximums and minimums. A surviving spouse typically receives a majority portion. Additional percentages may apply for one or more children, up to a combined cap.
• If there is no spouse or child, other dependents may qualify at lower percentages, also subject to an overall cap.
• Benefits are usually paid periodically by the insurance carrier. You may receive payments while the claim is pending if the carrier accepts liability. If there is a dispute, payments may start after a decision.
• Funeral expenses are reimbursed up to the statutory cap when you submit proper documentation.

Final checklist before you send

• Form LS-262 is complete, signed, and dated.
• Death certificate attached.
• Relationship and dependency documents attached.
• Medical evidence attached or pending with an explanation.
• Wage documents attached if available.
• Funeral bill attached if seeking reimbursement.
• Copies made for your records.
• Proof of mailing retained.

Your goal is simple: file timely, supply the key facts, and respond quickly to any follow-up. Form LS-262 is the right tool to start that process and secure the benefits the law provides to survivors.

Legal Terms You Might Encounter

• Claimant means the person filing this form. You are the claimant if you are the surviving spouse, child, other dependent, or the legal representative of the deceased worker’s estate. On this form, you identify your relationship to the deceased and explain why you qualify to claim benefits.
• Beneficiary refers to the person who may receive death benefits. A beneficiary can be a spouse, child, or other dependent who relied on the deceased for support. On this form, you list each potential beneficiary, including their dates of birth and status, so the program can determine eligibility and payment shares.
• Dependent means someone who relied on the deceased worker for financial support at the time of death. Dependents often include a spouse, minor children, students, or disabled adult children. When you complete this form, you will need to prove dependency with documents, such as marriage, birth, or school records.
• Average Weekly Wage (AWW) is the wage figure used to calculate death benefits. It is based on the deceased worker’s earnings before the injury, illness, or exposure that led to death. You may be asked to provide pay stubs, tax forms, or employer statements that support the AWW listed in the claim.
• Compensation Rate is the percentage of the AWW used to compute weekly payments to eligible beneficiaries. Different categories of beneficiaries receive different shares, and there is a cap on the total. On this form, you do not calculate the final amount, but accurate wage and dependency data help ensure the rate is set correctly.
• Causation is the link between the worker’s employment and the injury or illness that caused death. You must show that the death resulted from a work-related injury, disease, or exposure. This form gathers facts about the job, the incident or exposure, medical treatment, and the cause of death to support that connection.
• Funeral Expenses are burial and memorial costs related to the worker’s death. The program may reimburse reasonable funeral expenses up to a set limit. On the form, you can note funeral costs and later submit itemized bills and proof of payment if you are seeking reimbursement.
• Occupational Disease is an illness caused by workplace conditions, including long-term exposure to harmful substances. If death followed an occupational disease, you may need to provide medical reports that connect the disease to the job. On the form, identify the dates of exposure and the employers involved.
• Statute of Limitations is the filing deadline for a death benefits claim. Generally, you must file within a set period after the death or after you knew the death was work-related. On this form, accurate dates of injury, exposure, and death help show that you filed on time.
• Guardian or Personal Representative is the adult authorized to act for a minor child or an adult who cannot manage their affairs. If you are filing for a child or on behalf of an estate, you may need appointment papers. On the form, the guardian or representative signs and includes proof of authority.

FAQs

Do you need to file even if the employer already knows about the death?

Yes. Notice to the employer is not the same as filing a formal claim. This form starts your claim for death benefits. File it even if the employer reported the death to the insurer or government. Filing preserves your rights and sets the review process in motion.

Do you qualify if the death happened long after the original injury or exposure?

Possibly. If the death was caused by the earlier work-related injury or exposure, you can still qualify. You will need medical evidence that connects the cause of death to the work injury or disease. Provide the date of last exposure, the employers involved, and the medical records that support the link.

Do you have to list all children and dependents on the form?

Yes. List every child and dependent, even if you are not sure they qualify. Include full names, dates of birth, addresses, and relationship to the deceased. Missing a dependent can delay the claim or result in incorrect benefit shares. The program will determine final eligibility.

Do you need original documents, or will copies work?

Submit copies with the form unless you are asked for originals. Use clear, legible copies of the death certificate, marriage certificate, birth certificates, school records, guardianship orders, and wage records. Keep the originals in a safe place. You may be asked to present originals later.

Do you need a lawyer to file this form?

You can file without a lawyer. The form is designed for self-represented claimants. That said, you can seek help if the case is complex, involves disputed causation, multiple employers, or questions about dependency. If you hire a representative, note that on the form and keep communication centralized.

Do you have to wait for a claim number before submitting supporting documents?

No. You can file the form and then send supporting documents as you gather them. However, include as much as you can up front to avoid delays. Once you receive a claim number, put it on every document you send so your records are matched correctly.

Do student dependents over age 18 qualify?

They may. A dependent child who is a full-time student may qualify beyond age 18. Provide proof of full-time enrollment and the school’s contact information. You must update the records if the student’s status changes.

Do adult children with disabilities qualify?

They may if they were dependent on the worker at the time of death. Provide medical documentation of the disability and evidence of reliance on the deceased for support. You or the appointed guardian should sign the form and include proof of authority.

Checklist: Before, During, and After the Form LS-262 – Claim for Death Benefits

Before signing: Information and documents to gather

Identity and vital records:

• Certified death certificate.
• Marriage certificate (for spouse claims).
• Birth certificates for children; adoption or guardianship papers if applicable.
• Photo ID for the claimant and any guardian or representative.

Employment and wage proof:

• Pay stubs and tax forms from the year before the injury, illness, or last exposure.
• Employer’s name, address, and contact person.
• Dates of employment and job title.

Injury, illness, and exposure details:

• Date of injury or last exposure to harmful conditions.
• Location and description of the incident or exposure.
• Medical records linking the death to the work injury or disease.
• Treating physician’s name and contact information.

Insurance and claim history:

• Any prior claim number related to the injury or disease.
• Employer’s insurance carrier name and claim number, if known.

Dependent status evidence:

• School verification for student dependents.
• Medical records for disabled adult dependents.
• Proof of financial support if claiming as another dependent.

Funeral and medical expenses:

• Itemized funeral bill and proof of payment.
• Final medical bills related to the fatal condition.

Representation and authority:

• Appointment papers for a guardian or personal representative.
• Contact information for any attorney or accredited representative.

During signing: Sections to verify carefully

Names and identifiers:

• Spell the deceased worker’s name exactly as on the death certificate.
• Confirm dates of birth, dates of injury or exposure, and date of death.

Employer and employment data:

• Verify employer name and address. Use the legal business name.
• Check job title and employment dates for accuracy.

Causation narrative:

• Ensure the description of the injury or exposure is clear and factual.
• Align the cause of death on the certificate with your narrative and medical records.

Beneficiary listing:

• List all potential dependents with full names, birth dates, and relationships.
• Note full-time student status and disabilities where applicable.

Contact information:

• Provide a current mailing address, phone number, and email.
• Include contact information for your representative, if any.

Signatures and authority:

• Sign and date the form. If you are a guardian or representative, include your title.
• Attach proof of authority if signing for someone else.

Attachments and references:

• Identify what documents you are attaching.
• Write the claim number on each page if you have one; if not, add the deceased’s name and date of death on every page.

After signing: Filing, notifying, and storing

Filing:

• File the original form with the proper office. Use a trackable delivery method if mailing.
• If you file electronically, save the submission confirmation or receipt.

Notice:

• Send a copy to the employer and the insurance carrier, if known.
• Tell your representative, if you have one, that the claim has been filed.

Recordkeeping:

• Keep a complete copy of everything you submit, including envelopes and receipts.
• Store originals of vital records in a secure place.

Follow-up:

• Calendar key dates, including the filing date and any deadlines you receive.
• Watch for requests for additional information and respond promptly.

Updates:

• Report any change of address, phone number, or email immediately.
• Notify the claims office of any change in dependent status, such as a student dropping below full-time.

Common Mistakes to Avoid

• Don’t forget to connect the death to the work injury or exposure. Missing or weak medical evidence is a common reason for delays or denials. Ask the treating physician to provide a clear statement explaining how the work injury or exposure led to death and include key records.
• Don’t omit dependents. Failing to list a child, student, or disabled adult dependent can cause underpayment or later reallocation of benefits. It can also slow the claim while the office searches for missing information. List everyone who may qualify and let the program decide eligibility.
• Don’t guess the wage information. Estimating the average weekly wage without documents can lead to incorrect benefit amounts. Supply pay stubs, tax forms, or employer statements. If wages varied, include several months of records to show the pattern.
• Don’t miss the filing deadline. Late claims can be barred. If you are close to the deadline, file the form immediately and send supporting documents as you obtain them. Use a trackable method and keep proof of timely filing.
• Don’t send only originals without copies. Documents can be misplaced. Keep scanned copies and submit legible duplicates with the form. Bring originals only if you are asked to show them.

What to Do After Filling Out the Form

1. File the form and confirm receipt. Use a trackable mailing service or an approved electronic method. Keep the receipt and any confirmation page. Write down the date you filed and the address or portal used.
2. Share copies with key parties. Send a copy to the employer and the insurer if you know the claim details. If you have a representative, provide them with the full packet and the proof of filing.
3. Organize your evidence file. Create a checklist of documents you submitted and documents still pending. Group items by category: identity, wage, medical, dependency, and expenses. As you receive requests, you can respond faster.
4. Watch for a claim number. Once assigned, put the claim number on all future correspondence. If you do not receive one after a reasonable time, follow up with the office and provide your filing date and the deceased’s name and date of death.
5. Respond to information requests quickly. If the office asks for more medical records, wage proof, or dependency documents, send them by the deadline. Use the claim number and include a brief cover note summarizing what you are providing.
6. Manage benefit start-up. If benefits are approved, review the payment explanation. Confirm the beneficiary shares, the weekly rate, and the start date. Compare the wage basis in the decision with the wage documents you submitted. Flag any discrepancies promptly.
7. Track school and dependency changes. For student dependents, the calendar school term start and end dates. Send updated enrollment verification before each term as instructed. For disabled adult dependents, keep current medical documentation. Report any change in dependency right away.
8. Report life events that affect benefits. Notify the claims office about remarriage, a child reaching the age threshold, a change in guardianship, or a dependent moving. Reporting early helps prevent overpayments.
9. Request reimbursement for funeral and final medical expenses. Submit itemized bills and proof of payment. Include the claim number and the deceased’s name on every page. Ask for a written confirmation of what will be reimbursed.
10. Correct errors with a supplement. If you notice a mistake after filing, send a signed supplemental statement that fixes the error. Reference the claim number, identify the section you are correcting, and attach supporting documents.
11. Handle disputes methodically. If you receive a notice that the claim is contested, gather the issues and your supporting evidence. Keep communications professional and complete. Note deadlines on your calendar and submit responses on time.
12. Keep your address current. Payment and notice delays often trace back to outdated contact information. File a change-of-address notice as soon as you move or change phone numbers or email.
13. Maintain a long-term file. Keep copies of all submissions, decisions, payment records, and correspondence. Use a binder or digital folder with consistent naming. This makes audits, updates, or appeals easier to manage.
14. Plan for taxes and recordkeeping. Benefits may have tax implications. Keep annual benefit statements and payment summaries in one place. Consult a qualified tax professional if you have questions.
15. Prepare for periodic reviews. Some beneficiaries receive periodic eligibility checks. For students, that may be every term. For other dependents, it may occur annually. Respond promptly with the requested proofs to avoid payment interruptions.
16. If you add a new dependent later, file an update. For example, if a child is born after the worker’s death or a previously unknown dependent comes forward, send a supplemental filing with proof of eligibility. The claims office will re-evaluate the shares.
17. If payments stop or change unexpectedly, ask for an explanation in writing. Compare the reason with your files and submit any missing documents. If the change is tied to a dependency update, provide current proof and request reinstatement if appropriate.