The Industrial Commission administers and adjudicates claims filed by the dependents of public safety employees who are killed in the line of duty. The statute governing these claims is the Public Safety Employees' Death Benefits Act.  The Industrial Commission has adopted rules, known as the Public Safety Employees' Death Benefits Act Rules, which apply to claims filed under the Public Safety Employees' Death Benefits Act and which set forth Industrial Commission procedures related to its administration and adjudication of these claims.

Forms

Public Safety Employees' Death Benefits Act Claim Form

Documents to be Submitted with Claim for Benefits Under the Public Safety Employees' Death Benefits Act

1. A fully completed and notarized Public Safety Employees' Death Benefits Act Claim Form signed by the claimant(s), including current mailing address, email address, and phone number. (Note: If the mailing address changes during the pendency of the claim before the Commission the claimant(s) should immediately notify the Commission)
2. Documentation from the employer to establish that Decedent was a "law enforcement officer," "firefighter," "rescue squad worker," or other "covered person" under the definitions set out in N.C. Gen. Stat. § 143-166.2.
3. For firefighter or rescue squad worker, whether paid or volunteer, the certified roster and Articles of Incorporation for the employer.
4. The employer’s incident report, including any written statements from co-workers.
5. The employer’s duty log for the 24 hours preceding the incident that caused the death, showing Decedent’s work assignments.
6. Any emergency services records.
7. Certified copy of Decedent’s Death Certificate.
8. Any autopsy report.
9. If Decedent was murdered, documentation of that, such as a police report.
10. Any other documentation that may aid in the determination that Decedent’s death resulted from an incident experienced while in the course and scope of his/her official duties and while in the discharge of his/her official duties, as “official duties” is defined in N.C. Gen. Stat. § 143-166.2(9).
11. If the death was from a myocardial infarction suffered within 24 hours after participating in a training exercise or responding to an emergency situation, documentation to establish the training or the response to the emergency situation.
12. If the claim is for a firefighter who died of one of the enumerated cancers in N.C. Gen. Stat. § 143-166.2(6)e. (mesothelioma, testicular cancer, cancer of the small intestine, esophageal cancer, oral cavity cancer, and pharynx cancer), a notarized affidavit from the attending physician to establish that, or medical records that clearly establish that Decedent died as a direct and proximate result of one of the named cancers.
13. If there is any North Carolina workers’ compensation claim pending related to Decedent’s injury and/or death, the North Carolina Industrial Commission File Number for that claim.

If There is a Surviving Spouse

1. Certified copy of marriage license for a surviving spouse, if any.
2. Notarized affidavit from surviving spouse that he/she (1) resided with Decedent at the time of and during the six months preceding the date of injury to the Decedent that resulted in his/her death, and (2) also resided with Decedent from that date of injury up to the date of Decedent’s death. (Note: The initial six-month residency requirement does not apply if the marriage occurred during the six-month period or if the Decedent was absent during the six-month period due to service in the Armed Forces of the United States. If the Armed Forces exception applies, provide supporting documentation.)

If There is No Surviving Spouse, but There Are Surviving Dependent Children

1. If Decedent was formerly married, divorce decree or separation agreement if Decedent and his/her most recent spouse were divorced or separated, or Death Certificate of most recent spouse.
2. Certified copy of birth certificate for any child who was under the age of 18 and receiving his/her chief support from Decedent at the time of Decedent’s death.
3. For any and all children from No. 2 above, notarized affidavits of dependency from each child’s legal guardian or custodial parent and/or child support decrees to satisfy the “chief support” requirement of N.C. Gen. Stat. § 143-166.2(3).
4. Certified copy of birth certificate for any child over the age of 18 who is physically or mentally incapable of earning a living. For any such child, documentation (such as SSDI determination) to satisfy the “physically or mentally incapable of earning a living” requirement of N.C. Gen. Stat. § 143-166.2(3), and documentation of guardianship of the person.
5. Notarized affidavit from each minor and/or mentally incompetent child’s legal guardian or custodial parent who may receive benefits on such child’s behalf that the benefits will be used solely for the benefit of the child.
6. Documentation of current full-time student status for any child who was over the age of 18 and enrolled as a full-time student at the time of Decedent’s death.

If There Is No Surviving Spouse and No Surviving Dependent Children, But There is a Surviving Parent

If There is No Surviving Spouse, No Surviving Dependent Children, and No Surviving Dependent Parents