Claim for Death Benefits

Carrier's Number 

U.S. Department of Labor

Office of Workers' Compensation Programs

1. Name of deceased employee (First, Middle Initial, Last)

a. Social Security Number (Required by Law)

OMB No. 1240-0014

12. Nature of injury or occupational Illness and cause of death (Give parts of body affected if Injured)

5. Amount of undertaker's bill 6. Amount Paid 13. Name and address of last attending physician (or hospital)

e. Date married to deceased f. Place of marriage (City, State, Country) g. Signature of widow, widower, and/or Date

guardian of children

15. Children of deceased (see page 2 for qualification)

b. Address c. Social Security Number

(Required by Law)

a. Full name d. Date of birth

16. All other persons partially or wholly dependent on deceased b. income for one year preceding c. Relationship d. Age e. Dependent

Source Amount Wholly Partially

Important Notice

Section 31 (a)(1) of the Longshore Act, 33 U.S.C. 931 (a)(1), provides, as follows: Any claimant or representative of a claimant who knowingly and

willfully makes a false statement or representation for the purpose of obtaining a benefit or payment under this Act shall be guilty of a felony,

and on conviction thereof shall be punished by a fine not to exceed $10,000, by imprisonment not to exceed five years, or by both.

Form LS-262

Rev. Nov 2023

OWCP Number 

3. Name and address of employer (number, street, city, state, ZIP) 

4. Name and address of undertaker

a. Full name and address

Guardian?

f. Full name and address

Guardian?

11. Date of Injury

9. Date of Death 2. Last address of last deceased (number, street, city, state, ZIP, 8. Place of Death

10. Exact place where accident occurred (Street address,

7. Name of person paying undertaker's bill

Signature

Signature

Date (mm/dd/yyyy)

Date (mm/dd/yyyy)

a. Full name and address b. Social Security Number

e. Nationality

c. Date of birth d. Nationality

14. Widow or Widower

support (See page 2 for instructions)

Telephone Number

Expires: 11/30/2026

city, town, country) (For Longshore also include: name of 

vessel, pier, terminal, etc.) (For DBA also include: name 

of the DOD facility or associated worksite - i.e. base, FOB, 

camp, etc.)

 death

 country)

3a. Injury is reported under the:
Instructions:

1. Use this form to claim death benefits under the Longshore andHarbor 

Workers' Compensation Act, Defense Base Act, Outer Con-tinental 

Shelf Lands Act, or Nonappropriated Fund InstrumentalitiesAct. The 

information provided will be used to determineentitlement to benefits. 

2. Please submit electronically through the DFELHWC’s Secure 

Electronic Access Portal (SEAPortal) (preferred method) https://

seaportal.dol.gov/portal/

or to the Case Create Fax Number (202) 513-6814. Alternatively, 

submit the claim by mail to the Central Mail Receipt site at: 

U.S. Department of Labor Office of Workers’ Compensation Programs 

Division of Federal Employees’, Longshore and Harbor Workers' 

Compensation 400 West Bay Street, Suite 63A, Box 28 Jacksonville, FL 

32202 

(Please be sure to include your case number.)

3. individual claims must be filed by or in behalf of each personeligible for 

benefits [33 U.S.C. 913(a)]. (included are grandchildren,brothers and sisters 

under 18 years, parents, step-parents, parentsby adoption, parents-in-law, and 

any person who for more thanone year prior to the employee's death stood in 

place of a parentto them.) 

4. Under item 16(b), state all your income for the year precedingdeath by source 

(Social Security pension, bonds, etc.) and amount.List separately support 

deceased furnished you, including the value ofany shelter, food, clothing, or other 

supplies. Use space below oradditional sheets if needed. 

5. A person other than the claimant may complete claim for thebeneficiary. 

6. Persons are not required to respond to this collection of informationunless it 

displays a currently valid OMB number.

Conditions of Eligibility What terminates widow's or widower's benefits?

Coverage for Death Benefit 1. Death

2. Remarriage, in which case the widow or widower receives a lump

sum payment of two year's compensation. A death benefit is payable under the Longshore Act, or related law, if

a covered employee dies as a result of work-related injury or

occupational disease. What evidence is needed to support a claim?

Who is eligible for a Death Benefit?

1. Widow or widower. Proof of marriage to deceased worker. If

either party was married before, proof that earlier marriage was

legally ended. A certified copy of the final divorce decree, or proof of

death of a previous marriage partner may be required before benefits

are paid. Certified copy of the death certificate of the deceased

worker.

1. The deceased worker's widow or widower living with or dependent

for support at the time of death; or widow or widower living apart for

good cause or because of desertion by worker.

2. Unmarried child(ren) under age 18, or if over 18: (a) was (were)

wholly dependent on deceased worker and unable to support

self(ves) because of mental or physical disability, or (b) student(s) up

to age 23 (must meet certain requirements). Includes a posthumous

child, legally adopted child, child to whom deceased acted as parent

for one year before injury, stepchild, or acknowledged illegitimate

child.

2. Children - Certified copy of birth certificate or Order of Adoption. If

a legal guardian has been appointed, a certified copy of the Letters of

Guardianship.

Time requirement of filing claim

3. If the combined amount due a surviving widow or widower and

child or children is not greater than two-thirds (66 and 2/3 percent) of

the worker's average weekly wages subject to a maximum benefit of

200 percent of the national average weekly wage, a benefit is

payable for any one of the following: Grandchildren, brothers or

sisters (if dependent at time of injury), parents, grandparents, or others

satisfying legal requirements of dependency. (Consult the Office of

Within one year of employee's death. The time may not begin to run,

however, until the person claiming the benefit would reasonably have

related the employee's death to his or her employment. In case of

death due to an occupational disease, a claim may be filed within two

years after the claimant becomes aware, or in the exercise of

reasonable diligence or by reason of medical advice should have

been aware, of the relationship between the employment, the disease

Workers' Compensation Programs for more information.) and the death.

Use the space below or a separate sheet of paper to continue answers. Please number each answer to correspond to the number

of the item being continued.

Note: The notice applies to all forms requesting information that you might receive from the Office in connection with the processing and/or 

adjudication of the claim you filed under the LHWCA and related statutes.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid 

OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes/hours per response, including time for 

reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 

The obligation to respond to this collection is “required to obtain or retain benefits” . Send comments regarding the burden estimate or any other aspect of this 

collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers' Compensation Programs, 200 

Constitution Avenue, N.W., Room S-3524, Washington, DC 20210. Note: Please do not return the completed form to this address.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE

Privacy Act Notice

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a) you are hereby notified that (1) the Longshore and Harbor Workers' Compensation Act, 

as amended and extended (33 U.S.C. 901 et seq.) (LHWCA) is administered by the Office of Workers' Compensation Programs of the U.S. Department of Labor, 

which receives and maintains personal information on claimants and their immediate families. (2) Information which the Office has will be used to determine 

eligibility for and the amount of benefits payable under the LHWCA. (3) Information may be given to the employer which employed the claimant at the time of 

injury, or to the insurance carrier or other entity which secured the employer's compensation liability. (4) Information may be given to physicians and other 

medical service providers for use in providing treatment or medical/vocational rehabilitation, making evaluations and for other purposes relating to the medical 

management of the claim. (5) Information may be given to the Department of Labor's Office of Administrative Law Judges (OALJ), or other person, board or 

organization, which is authorized or required to render decisions with respect to the claim or other matter arising in connection with the claim. (6) Information may 

be given to Federal, state and local agencies for law enforcement purposes, to obtain information relevant to a decision under the LHWCA, to determine whether 

benefits are being or have been paid properly, and, where appropriate, to persue salary/administrative offset and debt collection actions required or permitted by 

law. Disclosure of the claimant's Social Security Number (SSN) or tax identifying number (TIN) on this form is mandatory. The SSN and/or TIN and other 

information maintained by the Office may be used for identification, and for other purposes authorized by law. (8) Failure to disclose all requested information may 

delay the processing of the claim, the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.

Rev. Nov 2023

Form LS-262

Page 2