12th Annual Federal Workers' Compensation Conference S i #39 ...
12th Annual Federal Workers' Compensation Conference S i #39 ...
12th Annual Federal Workers' Compensation Conference S i #39 ...
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REPORT OF PUBLIC SAFETY<br />
OFFICER’S DEATH<br />
• OMB FORM 1121-0025<br />
• Part 1 – Notice of Line of Duty<br />
Death of Public Safety Officer<br />
• For Law Enforcement,<br />
Corrections Officer, Probation<br />
Officer, Parole Officer, Fire<br />
Fighter, Judicial Officer,<br />
Ambulance and Rescue Squad<br />
Member, Other<br />
• Release of Information form<br />
• May require coroner’s<br />
report/death<br />
certificate/Autopsy Findings<br />
• Address the injury and time of<br />
death information<br />
• Send documents to:<br />
• Public Safety Officers Benefits<br />
(PSOB) Office<br />
• Bureau of Justice Assistance<br />
• 810 7 th Street, NW<br />
• Washington, DC 20531<br />
• Paid: $303.064 064 (If parents<br />
are separated ½ will go to<br />
each parent. If one parent<br />
cannot be located, then ½ will<br />
be held back until the parent<br />
can be located or a death<br />
certificate is provided.<br />
53
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