D9182 Claim for compensation of Funeral Expenses and ...

SECTION DDependants DetailsPlease:• detail below all dependants of the deceased. Where addresses and contact details are the same in section C write “asabove”;• ensure evidence relating to economic support as detailed in covering page is provided with claim;• if there is insufficient space use blank paper for further additional dependants;• ensure all dependant information is provided. Section 17(10) of the SRCA reads: Where claims for compensation under thissection are made by or on behalf of 2 or more dependants of a deceased employee, Comcare shall make one determinationin respect of those claims. Therefore no further dependant claims can be made at a later date.Dependant 122 Full nameIf the same as Claimantplease write “as per Claimantdetails”23 Home addressIf the same as Claimantplease write “as per Claimantdetails”24 Postal addressIf the same as Claimantplease write “as per Claimantdetails”Title Mr Mrs Miss Ms OtherSurnameGiven name(s)POSTCODEPOSTCODE25 Contact details Home telephone [ ]If the same as Claimantplease write “as per Claimant Work telephone [ ]details”MobileFacsimile [ ]E-mail26 Date of birthIf the same as Claimant/ /please write “as per Claimantdetails”27 Gender Male Female28 Relationship to deceased(e.g. partner, son, daughter).29 Was dependant 1 living withthe deceased immediatelybefore the date of death?NoPlease attach a copy of relevant information to verify relationship e.g. birth certificateYes30 Was dependant 1 dependenton the deceased foreconomic support at thedate of death?No Yes Wholly Mainly PartlyIf between the ages of 16 and 25 years, is this dependant a student?No Yes Full time Part timeD9182 11/13 P7 of 12