1. (a) In order for a legal beneficiary, other than the subsequent injury fund, to receive the benefits available as a consequence of the death of an employee which results from a compensable injury, a person shall file a written claim for compensation with the commission within one year after the date of the employee's death.

2. (b) The claim should be on a Form TWCC 42 prescribed by the commission and should include the following:

   1. (1) the claimant's name, address, telephone number (if any), social security number, and relationship to the deceased employee;
   2. (2) the deceased employee's name, last address, social security number (if known), and workers' compensation claim number (if any); and

   3. (3) other information, as follows:

      1. (A) a description of the circumstances and nature of the injury (if known);
      2. (B) the name and location of the employer at the time of the injury;
      3. (C) the date of the compensable injury, and date of death; and
      4. (D) other known legal beneficiaries.
3. (c) Each claim shall be accompanied by a copy of the deceased employee's death certificate. In addition, each claimant shall file evidence that establishes that the claimant is a legal beneficiary under the Act, §4.42. (See §§132.2-132.6 of this title (relating to Determination of Facts of Dependent Status; Eligibility of Spouse To Receive Death Benefits; Eligibility of a Child To Receive Death Benefits; Eligibility of a Grandchild To Receive Death Benefits; and Eligibility of Other Surviving Dependent's To Receive Death Benefits) for required proof of eligibility.)
4. (d) Each person must file a separate claim for death benefits, unless the claim expressly includes or is made on behalf of another person.

5. (e) Failure to file a claim for death benefits within one year after the date of the employee's death shall bar the claim of a legal beneficiary, other than the subsequent injury fund, unless:

   1. (1) that legal beneficiary is a minor or otherwise legally incompetent; or
   2. (2) good cause exists for failure to file the claim in a timely manner.

Source Note:The provisions of this §122.100 adopted to be effective January 25, 1991, 16 TexReg 174.