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GOVERNMENT EMPLOYEES RETIREMENT SYSTEM 3438 Kronprindsens Gade, GERS Complex- STE 1, St. Thomas, VI 00802-5750 (340) 776-7703  Fax (340) 776-4499 3004 Orange Grove, Christiansted, St. Croix, VI 00820-4313  (340) 718-5480  Fax (340) 718-5497 DUTY-CONNECTED DEATH ANNUITY STATEMENT OF EMPLOYING UNIT Under the law governing the Employees Retirement System, a Duty-Connected Death Annuity is payable to one of the several individuals named in the law, if the death of the member is determined to be the proximate result of bodily injuries sustained or a hazard undergone while in the performance and within the scope of his duties, if such injuries or hazard were not the consequence of the willful negligence of the member. Name of Deceased____________________________ Address ___________________________________ 1. In what division was deceased employed? ______________________________ Date? _______, 20 ___. (Name of Division) 2. In what capacity was deceased employed? _________________________________________________ (Title of Position) 3. Do you know the deceased to be a member of the Employees Retirement System? _____Yes _____ No 4. How long have you known the deceased? __________________________ 5. According to the information you have, how did death occur? Describe ___________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ________________________________________________________________________________ 6. Was the accident sustained while the employee was performing the regularly assigned duties of his position? ____ Yes _____No 7. In your opinion, was the death caused by bodily injuries sustained or a hazard undergone while in the performance and within the scope of his duties? _____Yes _____No 8. According to the information you have, were the injuries resulting in death a consequence of or due to willful negligence on the part of the employee? _____Yes _____No 9. (a) The last payroll period in which the deceased received compensation was ______________________ (b) Salary or Wages paid to _______________________________________________ (Inclusive) 10. Is any refund of salary due from the deceased? _____Yes _____No I do hereby certify that the answers to the foregoing questions are complete and true to the best of my knowledge, information and belief. _________________________________ (Division Head) _________________________________ (Division, Board or Commission) Date ___________, 20_____ _________________________________ (City, State, Zip) GERS-BEN114B REV 06