North Carolina
Industrial Commission

July 19, 2001

MEMORANDUM

The purpose of this memorandum is to inform interested persons of death benefits that are available under Chapter 143 of the North Carolina General Statutes for Law-Enforcement Officers, Firemen, Rescue Squad Workers and Civil Air Patrol Members. The Act is administered by the North Carolina Industrial Commission and provides for death benefits of $25,000.00 in the event that an eligible member of your agency or department is killed in the line of duty (defined in N.C. Gen. Stat. §143-166.2(c)) or during the discharge of official duties (defined in N.C. Gen. Stat. §143-166.2(f)). The statutes, claim for benefits form and other important information about this Act are also included on this web page and may be accessed by clicking on the specific item.

Pursuant to N.C. Gen. Stat. §143-166.3, upon the death of an employee eligible to receive benefits, the following persons are entitled to receive death benefits in the following order of priority:

1. If there is a surviving spouse (defined in N.C. Gen. Stat. §143-166.2(e)) who was living with the decedent on the date of death and for at least six months immediately prior to the date of death, that spouse may receive the entire benefit amount.
    
2. If there is no eligible surviving spouse but there are dependent children (defined in N.C. Gen. Stat. §143-166.2(a)), the children shall divide that total benefit equally between them.
    
3. If there is no eligible spouse and no dependent children but there are eligible parents of the decedent (defined in N.C. Gen. Stat. §143-166.2(b)), the parent(s) shall receive the total benefit amount.
    
4. If there are no eligible beneficiaries under the Act, the benefit will go to the decedent's estate.

In order to apply for benefits, the decedent's spouse or representative of any dependent must provide the Industrial Commission with certain documentation. First, a Claim for Benefits Form must be filled out and submitted to the Commission. A copy of the form is available on this web page. If there is no surviving spouse and dependent children are entitled to the benefits, an Industrial Commission Application for Appointment of Guardian Ad Litem (Form 42 which is available on this web page) must be completed in addition to the Claim for Benefits Form.

All completed forms should be sent to Phillip Hopkins, North Carolina Industrial Commission, Docket Section, 4336 Mail Service Center, Raleigh, NC 27699-4336.

There are a number of documents which the Commission requires to establish the eligibility of the decedent to qualify for benefits under the Act, and to establish the eligibility of the beneficiary(s) to receive those benefits.

Documents from the Decedent's Employing Agency

1. A Death Certificate; an official autopsy report if applicable;
    
2. Official incident reports demonstrating that the death occurred in the line of duty or during the discharge of official duties; accident reports; witness affidavits;
    
3. The decedent's oath of office if one exists, a roster of membership which includes the decedent's name, or other proof of employment or membership in the employing agency;
    
4. The Articles of Incorporation (for firemen), proof of the agency's eligibility for membership in the N.C. Association of Rescue Squads (for rescue squad workers);
    
5. Employees of Police Agencies and the Civil Air Patrol are already registered with the state.

Documents from the Beneficiary

1. For the surviving spouse: a marriage certificate; an affidavit attesting to having lived with the decedent on the date of death and for at least six months immediately prior to the date of death.
    
2. For the dependent children: birth certificate(s); Industrial Commission Form 42 Application for Appointment of Guardian Ad Litem.
    
3. For dependent parent(s): the decedent's birth certificate, or in the alternative, documentation that the decedent was adopted by the claimant(s); affidavits of the parent(s) and disinterested parties attesting that the parent(s) were receiving total support from the decedent.
    
4. For the decedent's estate: documentation of the appointment of the administrator of the estate.

Once it is established that the decedent is eligible for benefits, if there is an eligible beneficiary, the Industrial Commission will issue an Order naming the beneficiary(s) and distributing the benefit payment schedule. If there are no beneficiaries, the Industrial Commission will issue an Order directing that the entire $25,000.00 benefit be distributed to the estate in a lump sum.

The beneficiary(s) receives $10,000.00 immediately, and $5,000.00 per year thereafter, until all $25,000.00 has been distributed. If the beneficiary is a surviving spouse, the three subsequent $5,000.00 payments will only be made if he or she continues to remain unmarried. If a beneficiary becomes ineligible for any of the remaining benefits and there are other eligible beneficiaries, the next in line will receive the remaining benefits. For example, if a surviving spouse remarries, the remaining benefits will go to any eligible dependent children. If there are no eligible dependent children, then the benefits would to dependent parents, if any. If there are no eligible dependents, the remaining benefits would go to the decedent's estate.

If there are any questions regarding eligibility for these benefits or what forms and documentation to provide to the Commission in order to obtain benefits, please contact Ray Young, Investigations Section, at (888) 891-4895 (toll free), or (919) 807-2568, or Phillip Hopkins, Docket Director, at (919) 807-2606. Mr. Young may also be reached via e-mail at youngr@ind.commerce.state.nc.us; Mr. Hopkins at hopkinsp@ind.commerce.state.nc.us. If you are unable to access the necessary Industrial Commission forms on this web page, the forms may be obtained by contacting the Industrial Commission Docket Director.

Thank you.

Forms

To view or print PDF files of the following forms, you must first download and install a free Adobe Acrobat Reader.

• Claim for Benefits Under the Law Enforcement Officers’, Firemen’s, Rescue Squad Workers’ and Civil Air Patrol Members’ Death Benefits Act, G.S. §143-166, et seq.
   

• Form 42—Application for Appointment of Guardian Ad Litem.

Rules

Rules of the Industrial Commission Relating to the Law-Enforcement Officers’, Firemen’s, Rescue Squad Workers’ and Civil Air Patrol Members’ Death Benefits Act

Statutes

Chapter 143. State Departments, Institutions, and Commissions.

Article 12A. Law-Enforcement Officers', Firemen's, Rescue Squad Workers' and Civil Air Patrol Members' Death Benefits Act.

§143-166.1. Purpose.

§143-166.2. Definitions.

§143-166.3. Payments; determination.

§143-166.4. Funds; conclusiveness of award.

§143-166.5. Other benefits not affected.

§143-166.6. Awards exempt from taxes.

§143-166.7. Applicability of Article.

§143-166.8 through §143-166.12 [Reserved for Future Codification Purposes].

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