Workers’ Compensation

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.

Learn about Survivor Benefits

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.
• 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

• Filing a Fatality Claim

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
• Phone:
  • (800) 580-6665
• Fax:
  • (518) 486-7510
• Email:
  • advinjwkr@wcb.ny.gov