When an injured worker dies due to a work-related injury or illness, that worker’s dependents (as defined by law) may file a claim to be reimbursed funeral expenses, you should file a Claim for Compensation in Death Case (Form C-62), and the appropriate documentation with the Board. Death claims must be filed within two years of the worker’s death. Immigration status is not a factor, nor is the surviving family's location.
Supporting Documentation
In addition to the Form C-62, the following documentation should also be filed:
- Affidavit for Death Benefits (Form-AFF-1)
- The AFF-1 may be filed by:
- A surviving spouse or the dependent child(ren) of the deceased;
- Dependent grandchildren;
- Dependent parents and grandparents.
- Dependent siblings.
- Non-dependent parents or the estate of the deceased if there is no surviving spouse or other dependent.
- The AFF-1 may be filed by:
- Proof of Death by Physician Last in Attendance on Deceased (Form C-64)
- The worker’s last treating physician files this form, stating how the deceased death is causally related to either the deceased’s work or to the deceased’s previous work-related injury.
- Proof of Burial and Funeral Expenses by Undertaker (Form C-65)
- The funeral home files this form.
Additional Information
Need Assistance?
If you need assistance, please contact the Advocate for Injured Workers.
You will need to provide the following information:
- The deceased worker's name
- The deceased worker's WCB case number
- Your telephone number with area code
- A brief description of the problem
- Address:
- NYS Workers' Compensation Board
Advocate for Injured Workers
328 State Street
Schenectady, NY 12305-2318
- NYS Workers' Compensation Board
- Phone:
- (877) 632-4996
- Fax:
- (518) 486-7510
- Email: