Maryland Survivor Benefits Claim Submission Form

Maryland Survivor Benefits Claim Submission Form

Please be advised that this form is for individuals who were Public Safety Officers whose lives were lost in their line of duty. If you have any questions about this program or need assistance with the completion of this application, please contact the Program Administrator below. Please note that adding the required attachments will expedite your claim.

Zoann C. Mouzone

Program Administrator

443-240-5474

Zoann.Mouzone1@maryland.gov

Date Submitted*

Claim Type*

Select

Name of Deceased*

Claim or Appeal Summary*

Please provide a summary of the reason you are filing this claim.

Name & Relationship of Person Completing This Form*

Email of Person Completing This Form*

Contact Phone*

Contact Address*

Please include street city, state

Agency/Organization of Deceased*

Agency Type*

Select

Cause of Death*

Loss Date*

Beneficiary Name(s)*

Please be sure to list all individuals and their relationship to the deceased that are entitled to the benefit. Each beneficiary will need to provide a birth certificate and State identification.

If the beneficiary is the spouse of the deceased, you must also submit a marriage certificate using the file upload below.

Beneficiary Certification*

I hereby certify that, to the best of my knowledge, the person or persons listed above are the authorized recipients of the benefits established under Md. Code, Public Safety, Section 1-202.

Document Submission

Please attach all of the required documents to expedite claim processing.

Submission Instructions: Click the box of each document you are submitting, then upload the file in the designated area below.

Documents can also be submitted via email to survivor.benefits@maryland.gov.

**FOR APPEALS YOU DO NOT HAVE TO RESUBMIT ANY PREVIOUSLY SUBMITTED DOCUMENTS BUT WILL NEED TO CHECK THE BOXES OF THOSE YOU HAVE PROVIDED**

Death Certificate*

This document is always required. Uploading this information will help expedite your claim.

Funeral Expenses*

This document is always required to include any donations towards the funeral costs.

Medical Records, if applicable

If you have any additional medical information pertaining to this claim, please attach as it will expedite your claim.

Beneficiary/Estate Documents, if other than spouse

If you are not the spouse of the deceased, please submit state identification and birth certificate for each qualified beneficiary.

Agency Endorsement Letter*

The agency endorsement letter is the correspondence from the place of employment of the deceased which verifies the employment status at the time of the loss and verification of the cause of death.

File Upload*

Please attach required documents as listed above here.

Drag and drop files here or

Send me a copy of my responses

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