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Workers’ Compensation Board

New York State
Workers' Compensation Board
328 State Street  Schenectady, New York 12305
Governor David A. Paterson

Subject No. 046-381

Affidavits for Death Benefits:New Combined Form AFF-1

Supersedes Subject Number 046-115, dated June 30, 2003, Change in the Processing of
Death Cases - New Forms AFF-1, AFF-2 and AFF-3, Affidavits for Death Benefits, with
respect to the affidavit forms.

Date: December 02, 2010

In Subject Number 046-115 dated June 30, 2003, the Board announced that in non-controverted claims for death benefits, the surviving dependents could submit their claims to the Board by affidavit, thereby limiting the need to appear before a Workers' Compensation Law Judge (WCLJ) at a formal hearing relative to the claim. With the sworn affidavit for death benefits in the Board's electronic case file, the WCLJ can review it along with all other documents in the file and issue a decision concerning appropriate awards accordingly.

In the seven years since the introduction of the affidavit for death benefits, the Board has processed many claims for death benefits upon receipt of the affidavit. When it is properly completed and notarized, with relevant documents attached and filed with the Board, the affidavit has significantly reduced the need for appearances and allowed a decision concerning death benefits to be filed expeditiously.

In our continuing effort to further enhance the process and make it easier for surviving dependents to file a claim, the Board has combined its three affidavit forms (AFF-1 for surviving spouse or dependent children; AFF-2 for dependent brothers, sisters, or grandchildren; AFF-3 for dependent parents or grandparents) into one combined affidavit form, AFF-1. In the new combined form, the instructions are clearer, the application sections are easier to navigate, and more space is provided for responses.

Combined death affidavit Form AFF-1 should be used only in those cases where the employer has not controverted or contested the claim for benefits. The affidavit is available on the Board's website ( where it can be located under the heading "Forms." It may also be obtained at any office of the Workers' Compensation Board or by calling the Board's toll-free Customer Service number at 1-877-632-4996. Claimants or other parties with questions about Form AFF-1 may call this number or the number of the Board's Advocate for Injured Workers, 1-800-580-6665, which is provided on the cover page of Form AFF-1.


Robert E. Beloten