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DEATH BENEFITS
Date Of Death:
Amount annually devoted to the support of the partial dependents, if any:
  $
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In the case of no total dependents and one or more partial dependents:
   
In the case of one total dependent and no partial dependents:
   
In the case of one total dependent and one or more partial dependents:
   
In the case of two total dependents and regardless of the number of partial dependents:
   
In the case of three or more total dependents and regardless of the number of partial dependents:
   

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WorkCompCentral
c/o Business Insurance Holdings, Inc.
PO Box 1010
Greenwich, CT 06836
(805) 484-0333