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GOVERNMENT EMPLOYEES’ RETIREMENT SYSTEM 3438 Kronprindsens Gade, GERS Complex- STE 1, St. Thomas, VI 00802-5751 (340) 776-7703  Fax (340) 776-4499 3004 Orange Grove, Christiansted, St. Croix, VI 00820-4313  (340) 718-5480  Fax (340) 718-5498 APPLICATION FOR DUTY-CONNECTED DEATH ANNUITY INSTRUCTIONS CLAIMANT’S STATEMENT must be made by the person or persons to whom the annuity is payable. If there is more than one claimant a statement must be furnished for each. When the annuity is payable to a minor, the statement must be made by a guardian, an official certificate of whose appointment must be furnished. If an official inquiry as to cause of death has been made, copy of the verdict, or finding, duly certified, must be furnished with this statement. A certified copy of the CERTIFICATE OF DEATH must be furnished with this statement. A CERTIFICATE OF DEATH can be obtained from the local Board of Health, or the Division of Vital Statistics. Any such certificate must bear the official seal of the agency issuing it or be properly notarized. A PHYSICIAN’S STATEMENT must be made by every physician who attended the deceased during his last illness, and for this purpose the System will furnish as many forms as are required. Every question must be distinctly and fully answered. The system reserves the right to require or to obtain further information should it be deemed necessary. PROVISIONS OF THE RETIREMENT ACT VIC3 CHAP 27 Section 709 - Duty - Connected Death Annuity (A) Upon death of a member before retirement as the proximate result of bodily injures 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 misconduct of the member, the surviving widow of the member shall be entitled to an annuity equal to forty Percent (40 %) of the annual compensation of the member at the date of death of the member, to continue during her widowhood. This annuity shall be increased by ten percent (10%) of the member’s compensation on account of each unmarried minor child under age eighteen (18) years, subject to a maximum payment to a widow and children of sixty percent (60%) of compensation. If there be no widow or if the widow dies or remarries before any child of such deceased member shall have attained the age of eighteen (18) years then each child under said age shall receive an annuity of ten percent (10%) of the member’s compensation, to continue until each child attains age eighteen (18), subject to a limitation of fifty percent (50%) of compensation to all minor children. If there be no widow or children under age eighteen (18) then payment of annuity shall be made to the dependent father and dependent mother of the member, at the rate of twenty-five percent (25%) of compensation to each, for life, provided, that if none of the aforementioned beneficiaries is living at the death of the member, no duty-connected death annuity shall be paid under the provision hereof. (B) Adopted children shall be eligible for benefits hereunder provided the proceedings for adoption shall have been initiated at least one year prior to the date of death of the member. GERS-BEN114A REV 06 GOVERNMENT EMPLOYEES’ RETIREMENT SYSTEM 3438 Kronprindsens Gade, GERS Complex- STE 1, St. Thomas, VI 00802-5751 (340) 776-7703  Fax (340) 776-4499 3004 Orange Grove, Christiansted, St. Croix, VI 00820-4313  (340) 718-5480  Fax (340) 718-5498 APPLICATION FOR DUTY-CONNECTED DEATH ANNUITY CLAIMANT’S STATEMENTS Membership No.______________ Note: The Employees Retirement System furnishes this form solely upon request, neither admitting the validity of the claim nor the liability of the System, nor waiving any right in the premises, and without indicating what action it may take upon this application before making out this statement, read instructions carefully. I, __________________________________________, the undersigned, residing at_____________________________________ (Print Name) (Address) _______________________________do hereby make application for a semi-monthly annuity as provided under 3 VIC Section 701 creating a retirement system for employees of the Government of the Virgin Islands on account of the death of ____________ __________________________________________which occurred on _____________________________as proximate result of (Full name of deceased member) (Date of Death) bodily injuries sustained or a hazard undergone while in the performance and within the scope of his duties in the position of _____ ____________________________________________, ___________________________________________________________ (Title of Position) (Name of Division) 1. Residence of deceased at death ___________________________________________________________________________ 2. a. Date and place of death _____________________________________ ____________________________________ (Date) (Place) b. Cause of death _______________________________________________________________________________________ (If injury, describe fully.) ______________________________________________________________________________________________________ 3. Was an inquest held? ________Yes ________No 4. Names and addresses of all physicians who attended deceased during his last illness and during five (5) years prior thereto: Name Address Date of Disease or Attendance Condition _____________________________________ ________________________ ______________ _______________________ _____________________________________ ________________________ ______________ _______________________ _____________________________________ ________________________ ______________ _______________________ _____________________________________ ________________________ ______________ _______________________ _____________________________________ ________________________ ______________ _______________________ 5. a. Date and place of deceased’s birth______________________ _______________________________________________ (Date) (Place) b. Source from which date of birth obtained ___________________________________________________________________ GERS-BEN114A REV 06 APPLICATION FOR DUTY-CONNECTED DEATH ANNUITY If widow of member, fill out this part of application: I am the lawful widow of the said deceased, to whom I was married on ______________in _______________________________ (Month), (Day) (Year) (City) (County) (State) I have been married continuously from said date up to and including the date of death, and I am now and have been continuously unmarried since such date of death. 1. I was born on ________________in ___________________________________________and am now _________years of age (Month), (Day) (Year) (City) (County) (State) (age) 2. I have the following named children under (18) years of age, their dates of birth and places of birth being as indicated below: Name Date of Birth Place of Birth __________________________________ ______________ _______________________________________ __________________________________ ______________ _______________________________________ __________________________________ ______________ _______________________________________ __________________________________ ______________ _______________________________________ __________________________________ ______________ _______________________________________ If guardian of minor child or children of said deceased, fill out this part of the application: 1. I am the legally appointed guardian of the following named children under (18) years of age: Name Date of Birth Place of Birth _________________________________ ______________ _______________________________________ _________________________________ ______________ _______________________________________ _________________________________ ______________ _______________________________________ _________________________________ ______________ _______________________________________ 2. My appointment as guardian was made in the________________________________________________________ (Name of Court) Court of ______________________ on _______________, 20______ (Attached is a certified copy of my appointment) If dependent father or mother, fill out this part of application: 1. I am the ___________________________ of the said deceased, and was entirely dependent for my support on the (Father or Mother) earning of the deceased. 2. I have been unemployed for _____years, and have no independent income of any kind except __________________________ (State nature of income, source) ______________________ (Amount) 3. I was born on _______________in _______________________________________________my present age being ___years. (Month), (Day) (Year) (City) (County) (State) Certification of Applicant: I hereby warrant the truth of the answers to the foregoing questions which are correct to the best of my knowledge, information and belief. Dated _________,20___. _________________________________________________ (Signature of Applicant) _________________________________________________ (Address of Applicant) Territory of the U.S. Virgin Islands } District of } ss: On this _____day of ________, 20____, before me personally appeared ______________________________known to be the individual who named is subscribed in the foregoing instrument and acknowledge that _____________________ executed the same as _________ free and voluntary act. ____________________________________ Notary Public Commission Expires_____________________ GERS-BEN114A REV 06