Section E: Do You Know of Anyone Else Who May Be Able to Get Death Benefits? Yes No If yes, complete this section. (Attach more pages if needed.) Name Relationship to person who died (First, Middle, Last) Address Phone number (Street, City, ZIP) (if known) (if known) Name Relationship to person who died (First, Middle, Last) Address Phone number (Street, City, State, ZIP) (if known) (if known) Name Relationship to person who died (First, Middle, Last) Address Phone number (Street, City, State, ZIP) (if known) (if known) Name Relationship to person who died (First, Middle, Last) Address Phone number (Street, City, State, ZIP) (if known) (if known) Name Relationship to person who died (First, Middle, Last) Address Phone number (Street, City, State, ZIP) (if known) (if known) You must send a copy of the employee’s certificate and documents to show how each person requesting benefits is related to the person who died. Examples: Certified copy of a marriage license, birth certificate, adoption decree, divorce decree, and related court orders. Sign Here Date Note: With few exceptions, upon your request, you are entitled to be informed about the information TDI-DWC collects about you; get and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). For more information about the procedure and costs for obtaining information from or about the procedure for correcting information kept by , please contact the Agency Counsel Section of 's Legal and Regulatory Affairs Program at or you may refer to the on our websites.
Section E: Do You Know of Anyone Else Who May Be Able to Get Death Benefits? Yes No If yes, complete this section. (Attach more pages if needed.) Name (First, Middle, Last) Relationship to person who died Address (Street, City, ZIP) (if known) Phone number (if known) Name (First, Middle, Last) Relationship to person who died Address (Street, City, State, ZIP) (if known) Phone number (if known) Name (First, Middle, Last) Relationship to person who died Address (Street, City, State, ZIP) (if known) Phone number (if known) Name (First, Middle, Last) Relationship to person who died Address (Street, City, State, ZIP) (if known) Phone number (if known) Name (First, Middle, Last) Relationship to person who died Address (Street, City, State, ZIP) (if known) Phone number (if known) You must send a copy of the employee’s certificate and documents to show how each person requesting benefits is related to the person who died. Examples: Certified copy of a marriage license, birth certificate, adoption decree, divorce decree, and related court orders. Sign Here Date Note: With few exceptions, upon your request, you are entitled to be informed about the information TDI-DWC collects about you; get and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). For more information about the procedure and costs for obtaining information from or about the procedure for correcting information kept by , please contact the Agency Counsel Section of 's Legal and Regulatory Affairs Program at or you may refer to the on our websites.
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