D9182 Claim for compensation of Funeral Expenses and ...
D9182 Claim for compensation of Funeral Expenses and ...
D9182 Claim for compensation of Funeral Expenses and ...
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SECTION A continuedDECEASED’S PERSONAL DETAILS8 Was the death subject to acoronial inquiry?NoYesPlease attach a copy <strong>of</strong> the coronial inquiry report9 Was a post mortem <strong>of</strong> thedeath held?NoYesPlease attach a copy <strong>of</strong> the post mortem report10 Were there any witnesses tothe death?NoYesPlease supply names <strong>and</strong> contact details <strong>of</strong> the witnessesMedical Treatment11 Please list treating doctors<strong>and</strong> hospitals that haveprovided treatment <strong>for</strong> anyinjury or disease that wasrelated to the death <strong>of</strong> themember.Date(s) <strong>of</strong> Treatment Name <strong>of</strong> doctor/hospitalType <strong>of</strong>treatment/consultation(e.g. specialist, GP)If insufficient space, please attach a separate sheetSECTION BDetails <strong>of</strong> <strong>Claim</strong>12 What type <strong>of</strong> claim are youmaking?Please tick the appropriate box.Dependant <strong>compensation</strong> only<strong>Funeral</strong> Benefits onlyBoth Dependant <strong>compensation</strong><strong>and</strong> <strong>Funeral</strong> BenefitsPlease continue complete sections C to G <strong>and</strong> IPlease continue complete sections E, H <strong>and</strong> IPlease complete the whole <strong>for</strong>m<strong>D9182</strong> 11/13 P5 <strong>of</strong> 12
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