Section 89.7. Claims for death benefits

(a) Claims for death benefits must be on the forms provided by the Bureau. The Department will make these forms available on its website and, upon request, by electronic mail, facsimile transmission or regular mail. The forms, completed in all applicable particulars, shall be forwarded to the Bureau of Risk and Insurance Management, Department of General Services, Post Office Box 1365, Harrisburg, Pennsylvania 17105-1365.

(b) The Claim for Death Benefits may be completed by a claimant, a political subdivision, or a Commonwealth agency but shall be signed by the claimant or authorized representative and be notarized.

(c) The following documents shall be attached to the Claim for Death Benefits:

(1) Certified copy of the death certificate.

(2) If payment is to be made to the spouse, evidence shown in § 89.6(b) (relating to beneficiary eligibility).

(3) If payment is to be made to or on behalf of minor children, evidence shown in § 89.6(c) and, if children are under 18 years of age, guardianship papers or court order to make payment.

(4) If payment is to be made to the parent or parents, evidence shown in § 89.6(d).

(d) The Report of Death shall be executed by a political subdivision or Commonwealth agency and be notarized.

(e) The following documents shall be attached to the Report of Death:

(1) A copy of the Workers’ Compensation form filed as a result of the death of the public safety officer.

(2) A notarized statement from the supervisor or officer in charge describing in detail the duties being performed by the public safety officer prior to or at the death and the circumstances under which the death occurred.

(3) Other information which will assist in determining eligibility to include:

(i) An autopsy report or a statement by the political subdivision or Commonwealth agency or coroner explaining that no autopsy was performed.

(ii) Investigation, incident and accident reports.

(iii) A determination of death by another state or Federal agency such as Workers’ Compensation or Social Security.

(iv) An attending physician’s narrative report containing the conclusion that the public safety officer died as a result of the performance of duties and stating the basis for the conclusion.

(4) Additional documentation for heart attacks and strokes to include:

(i) A detailed statement listing the actions of the public safety officer in the performance of duties during the 24-hour period prior to the onset of the heart attack or stroke.

(ii) Medical records related to the health of the public safety officer, including hospital admission/discharge reports, physician reports, physical examination results, and health risk and wellness evaluations covering the past 3 years.

(5) Additional documentation for death of a volunteer:

(i) A certified copy of documents, which establish that the volunteer ambulance service, volunteer fire company or volunteer rescue company is a nonprofit chartered corporation, association or organization located in this Commonwealth meeting the applicable definition established by the Volunteer Fire Company and Volunteer Ambulance Service Grant Act (35 P. S. § § 6942.101—6942.903).

(ii) A notarized statement of the political subdivision or Commonwealth agency that the volunteer was an officially recognized or designated member of the volunteer ambulance service, volunteer fire company or volunteer rescue company at the time of the volunteer’s death.

(iii) A complete description of deceased volunteer’s membership information.

(f) It is recommended that political subdivisions submit claims for determination of eligibility prior to payment.

The provisions of this § 89.7 amended November 16, 2007, effective November 17, 2007, 37 Pa. Code 6106. Immediately preceding text appears at serial pages (235109) to (235110).