Louisiana Administrative Code
Title 58 - RETIREMENT
Part XXIII - Survivor Benefit Board
Chapter 1 - Law Enforcement Officers and Firemens Survivors Benefit Board (Formerly LAC 37:I.Chapter 11)
Section XXIII-107 - Claims Requests (Formerly LAC 37:I.1101.E)

1. notarized affidavit for decedents date of employment, rank, duty assignment, routine work schedule, work responsibilities, years of classified service if applicable, and brief statement outlining injuries;

2. copy of decedents commission as police officer/fireman;

3. notarized affidavits from any witnesses to incident;

4. certified copy of investigative report, or uncertified copy accompanied by notarized affidavit of reporting investigative officer, which identifies copy of report as accurate reproduction of original report;

5. certified copy of decedents death certificate and autopsy protocol report;

6. notarized affidavit from decedents surviving spouse stating their full name, address, date of marriage, and that they were not legally separated or divorced at time of death. Also, a certified copy of marriage license;

7. list of names and birth dates of each minor child born to or adopted by decedent, certified copies of birth certificates;

8. certified copy of letters of tutorship;

9. notarized affidavit of tutor or legal representative of surviving child stating child is unmarried and under the age of 18, or alternately, is unmarried, under the age of 23, and a student;

10. notarized affidavit of caretaker of surviving child which states the major child is physically and/or mentally handicapped, totally and permanently disabled, and solely dependent upon decedent for support. Also, copy of the major childs medical and/or psychological records; and

11. if decedent was not survived by a spouse, child or children, a notarized copy of the departments form designating decedents chosen beneficiary. If decedent is not survived by a spouse, child or children, and no beneficiary designation form has been completed, any approved qualifying claim shall be paid to the decedents estate.

1. for claims involving disabling cancer under R.S. 33:2011, a certified copy of medical diagnosis of disabling cancer originating in the bladder, brain, colon, liver, pancreas, skin, kidney, or gastrointestinal tract, and leukemia, lymphoma, and multiple myeloma;

2. for claims involving diseases or infirmity of the heart or lungs under R.S. 33:2581, a certified copy of a medical diagnosis of disease of the heart or lung during period of classified fire service;

3. for claims involving heart attack or stroke under R.S. 40:1665.1, notarized affidavit providing that heart attack or stroke occurred while on duty while fireman was engaged in an activity which was stressful or physical, or participating in a training exercise that involved stressful or strenuous physical activity, or no later than 24 hours from engaging or participating in such activities, while on duty.